m 




w 





















% 






^ 











' <$> * o „ o v V O * 



BENJAMIN DRAKE, 



OBSERVATIONS 

ON 
THE DISTINGUISHING SYMPTOMS 

OF 

THREE DIFFERENT SPECIES 

OF 



CATARRHAL, THE APOSTEMATOUS. 

AND THE 

TUBERCULOUS; 



SOME REMARKS ON THE REMEDIES AND REGIMEN BEST FITTED FOR 
THE PREVENTION, REMOVAL, OR ALLEVIATION OF EACH SPECIES. 

TO WHICH IS ADDED, 



AN APPENDIX, 



PREPARATION AND USE OF LACTUCARIUM, OR LETTUCE- 
OPIUM. 

% 

BY ANDREW DUNCAN, Sen. M.D.F.R.& A.SS. Ed, 

PHYSICIAN EXTRAORDINARY TO THE KING, 

AND SENIOR PHYSICIAN TO THE PRINCE REGENT FOR SCOTLAND; 

ONE OF "THE PHYSICIANS IN ORDINARY TO THE PUBLIC DISPENSARY 

FOR THE CITY AND COUNTY OF EDINBURGH, ETC. 



FIRST AMERICAN, FROM THE SECOND LONDON EDITION. 



PHILADELPHIA: 

PUBLISHED BY COLLINS & CROFT, 

No. 73, MARKET STREET. 

W. Brown, Printer, Prune Street. 

1819. 



+*\:m. 



? *-^ TO 



HIS ROYAL HIGHNESS 



'9 

PRINCE REGENT OF THE BRITISH DOMINIONS, 

THIS SHORT TREATISE, 

AN ATTEMPT TO ALLEVIATE HUMAN MISERY, 
BY ENDEAVOURING TO IMPROVE THE HEALING ART, 

IS HUMBLY DEDICATED, 
BY A FAITHFUL SUBJECT OF THE BEST OF KINGS, 

AND ONE OF THE OLDEST MEMBERS OE THE HOUSEHOLD OF 

THE PRINCE OF SCOTLAND, 

ANDREW DUNCAN, Sen, 



A LETTER 

TO 

Sir GILBERT BLAINE, Baronet, 

one of the physicians in ordinary to his royal 
highness the prince of wales. 

My Dear Friend, 

More than forty years have now elapsed 
since I first began to deliver medical lectures 
at Edinburgh; and I have often reflected, with 
satisfaction, that you were one of the first of 
my hearers. Since that time, though our dif- 
ferent sit ations in life have prevented frequent 
intercourse, yet we have never ceased to be 
steady friends; and I have often had occasion 
to admire the integrity of yourlife as well as the 
solidity of your judgment. Permit me, there- 
fore, to present to you, as an early pupil, a 
a 2 



eandid critic, and a steady friend, this shon 
Treatise on Pulmonary Consumption : a disease 
which has long been ranked, and which, I am 
afraid, must still be ranked, among the oppro- 
bria medicomm. But we have no reason to 
despair of obtaining farther improvements in 
practice, either for the prevention, cure, or 
alleviation even of phthisis. I now, there- 
fore, take the liberty of submitting to the public 
in general, and to you in particular, the result 
of my own observations; and after you have 
carefully perused this little work, I confidently 
trust, that in return you will favour me with 
your opinion respecting the conclusions I have 
drawn from my practice. Some of these con- 
clusions you may have found confirmed, and 
others refuted by your experience. I am 
anxious to learn in what conclusions we agree, 
and in what we differ. If, therefore, more 
urgent business will permit you to communi- 
cate to me the result of your observations on 
pulmonary consumption, I shall esteem it a 
singular obligation; for, although now in the 
seventieth year of my age, I am not yet too old 



to learn ; and it will give me no slight degree of 
satisfaction once more to become the disciple 
of a quondam pupil, by whose judicious and 
candid remarks I have often before been in- 
structed. 

Believe me to be, 

Yours ever and sincerely, 

ANDREW DUNCAN, Sen. 

Edinburgh, ) 
20th Nov. 1813. J 

P. S. Since the date of the above letter, three 
years have been added to my life. And dur- 
ing that period, I have witnessed not a few de- 
plorable cases of phthisis terminating fatally. 
But from all that I have seen, I am still more 
confirmed in my opinion, that those prac- 
titioners err much who consider phthisis as 
always an incurable affection. In the incipient 
state even of tuberculous phthisis, a cure 
may often be effected; and even in the very 
last stage of every species much maybe done 
towards alleviation of human misery. Hence, 
you will not be surprised, that your quondam 



8 

preceptor, even in the evening of life, should 
consider phthisis as an object well meriting 
both his and your attention. 

Ut supra, A. D. 

October 20th, 1816. 



PREFACE 



I here present to the public a very short 
Treatise, on a very important subject. With 
little difficulty, I might have extended it to a 
much greater length. A particular relation 
or even a selection of those cases from which 
my observations have been deduced, might 
have filled a large volume. My object, how- 
ever, has been to lay before the intelligent 
reader, not the detail, but the result of ex- 
perience, and to state merely the conclusions 
I have drawn from the facts which I have 
witnessed in watching the progress of pul- 
monary consumption. 

If these conclusions have not been very 
generally erroneous, they have afforded useful 



X PREFACE. 

instruction to myself; and if an attentive perusal 
of them shall afford similar instruction to 
others, the object which I have in view by this 
publication will be completely obtained. 

Edinburgh, ) 
Nov. 30, 1813. j 



In the second edition of this short Treatise 
now presented to the public, the attentive 
reader will not find many alterations. And 
although, by the observations which have 
been communicated to me by intelligent medi- 
cal friends, as well as by cases which have 
fallen under my own care, I might have sw ell- 
ed it to a very considerable size ; yet, as my 
sole aim has been to communicate merely 
the result of experience, the size of the pre- 
sent edition will be found very little augmented. 
To the account, indeed, of the preparation 
and use of the Lettuce Opium, or Lactu- 
carium, as I have named it, some interesting 



PREFAGE, XI 

additions have been made. A nd let me here 
observe, that besides the use of that article in 
phthisis pulmonalis, I have found it highly 
beneficial in various other affections. 

I have particularly employed it with great 
advantage in many cases of Rheumatism,— a 
disease, which, I need hardly observe, is, in 
Britain, both a very common and a very pain- 
ful complaint. It is not, however, in every 
condition of rheumatism, that benefit is to be 
expected from lactucarium. That disease, 
as well as phthisis, has been divided into a 
variety of different species. Sauvages, in his 
elaborate System, has pointed out fifteen dif- 
ferent species, all of them, in his opinion, de- 
serving attention, from the difference in prac- 
tice requisite for combating each particular 
species. But the greater part of practitioners 
are not disposed to follow him in such minute 
distinctions. 

Even from the earliest periods of medicine, 
however, two states of this disease have been 



Xil PREFACE. 

established, from the circumstance of their re- 
quiring very different modes of cure. These 
are almost universally known in Britain by 
the appellations of Acute and Chronic Rheu- 
matism. And Dr. Cullen. to whose nosologi- 
cal labours the medical world are very much 
indebted, has viewed these modifications of 
the disease as differing so much from one an- 
other, that he has defined each as a separate 
genus. To the acute rheumatism, he has 
appropriated the name of Rheumatismus: to 
the chronic that of drthrodynia. The defi- 
nitions which he has given of each of these 
genera are accurate and judicious: and while 
they point out the obvious symptoms in which 
these genera differ in their appearance, 
thev also clearly demonstrate to the attentive 
reader, that the two affections must differ in 
their nature, and must require a different 
mode of treatment. 

It is not without great diffidence that I ven- 
ture to dissent from an authority in the prac- 
tice of medicine, for which I have uniformlv 



PREFACE. Xlll 

maintained the highest veneration. But in 
the clinical wards of the Royal Infirmary, 
and in my Lectures illustrating the cases which 
I have there an opportunity of treating, I have 
for many years pointed out a distinction in 
rheumatism, which, with a view to actual 
practice, seems to me to be more useful than 
the distinctions either of Sauvages or of 
Cullen. 

I am of opinion, that, with the view to a suc- 
cessful cure, four different modifications of 
rheumatism are especially to be had in view. 
And these I have in my Lectures distinguished 
by the names of Rheumatismus Inflamma- 
torius, Imtabilis, Jltonicus, and Paralyticus. 
They cannot with propriety be considered as 
different stages of the same disease. For al- 
though it be true, that the most common pro- 
gress of the affection is from the inflammatory 
to the irritable state, and that the irritable of- 
ten terminates in the atonic, and this again in 
the paralytic state; yet each modification may 
occur separately and independently of any 
b 



XIV PREFACE. 

other. The rheumatism us irritabilis, in par- 
ticular, every day takes place without any 
preceding inflammation, or at least any pre- 
ceding fever. The rheumatismus inflam- 
matorius, with a high degree of fever, and evi- 
dent marks of local inflammation at particular 
joints, not unfrequently supervenes, after the 
disease has previously existed in its irritable 
state for a considerable time. And in some 
though rare instances, the rheumatismus 
paralyticus is the very first form under which 
the disease appears, without any preceding 
marks either of inflammation, irritability, or 
even atony. Hence, notwithstanding the com- 
mon progress of rheumatism, there is, I 
think, good reason for establishing in the genus 
rheumatismus, the four species which have 
been mentioned, especially as they require 
very different modes of cure, and as they can 
readily be distinguished from each other by 
obvious symptoms. 

On h^ sub e t o" rheumatism, especially 
with a view to point out the distinction of the 



PREFACE. XV 

four species irom each other, and the par- 
ticular modes of cure best adapted for the re- 
moval of each, it is now many years since I 
stated my sentiments very fully, in a course of 
lectures, delivered at Edinburgh, on the prac- 
tice of medicine. Since that, 1 have often 
repeated these observations, in an abridged 
form, when illustrating, by clinical lectures, 
the cases of patients who were under my care 
subjected to rheumatism, in the Royal Infir- 
mary. In that hospital, all the four species of 
this disease which I have mentioned, are al- 
most every day to be met with. 

It was once my intention to have made my 
observations and opinions on rheumatism, as 
well as on consumption, the subject of a sepa- 
rate publication. But that intention, from 
different considerations, I have now relin- 
quished. I shall however, probably soon submit 
these Observations to the examination of my 
friends, without having recourse to the press. 
It is my intention to place my manuscripts on 
this subject in the Library of the Royal Col- 



XVI PREFACE. 

lege of Physicans of Edinburgh, where I have 
already deposited more than fifty volumes, 
written with my own hand, containing practi- 
cal remarks on cases which have fallen under 
my own observation. 

By this measure, I am not without hopes, 
that the experience which has afforded use- 
ful lessons to myself, may be of benefit to some 
of my younger brethren in the college. The 
presumption, indeed, is, that very few of them 
will find either leisure or inclination to read 
much of these manuscripts; but the volumes 
themselves, even without being read, will at 
least afford to future members of the Col- 
lege an example of industry, for the advance- 
ment of a science which aims at the allevia- 
tion of human misery. 

On the present occasion, I shall merely take 
an opportunity of stating, in a very few words, 
the grounds of distinction between the four 
species of rheumatism which I have elsewhere 
attempted to describe at considerable length 



PREFACE. XV11 

The rheumatismus inflammatorius, then, is 
chiefly distinguished by the concomitant fever^ 
by the obvious swelling of the joints, and by 
the aggravation of the pains from the action of 
external heat. In the rheumatismus irrita- 
bilis there is no concomitant fever, and there 
is rarely any swelling of the joints, but the 
pains are greatly aggravated by heat, par- 
ticularly by the heat of the bed. In the rheu- 
matismus atonicus, on the other hand, the 
pains are relieved by heat, as is mentioned in 
Dr Cullen's definition of arthrodynia or 
chronic rheumatism; fever is very rarely ob- 
served, and an obvious local affection of the 
pained parts is often present, even under the 
form of distortions and nodosity of the joints. 
The last species, the rheumatismus paraly- 
ticus, which, though less common than either 
of the others, is, however, not of unfrequent 
occurrence, is chiefly distinguished by the loss 
of muscular strength in the limbs most affect- 
ed, without, however, any diminution of sen- 
sibility, but often with a wasting of muscular 



XV111 PREFACE. 

flesh in those limbs which have been long 
subjected to the severe pains. 

By these marks the four different modifica- 
tions of rheumatism, which have been men- 
tioned, may, I think, be readily distinguished 
from each other in actual practice. And it is 
almost unnecessary to add, that the cure in 
each must be attempted on very different prin- 
ciples. The intentions of cure, which, in my 
opinion, are to be aimed at in each, I have 
long since stated in another publication, 
Heads of Lectures on the Theory and Prac- 
tice of Medicine. Here I shall only observe, 
that while in the rheumatismus inflammato- 
rius, the great object to be aimed at is the 
diminution of increased action by powerful 
evacuants, blood-letting and sudorifics, the 
rheumatismus atonicus is only to be success- 
fully combated by the restoration of due 
vigour from cold bathing and similar tonics. 
While, again, in the removal and alleviation 
of the rheumatismus irritabilis, much may be 
done, by counteracting the effects of morbid 



PREFACE. XIX 

sensibility and irritability. For answering 
this intention, I have found no remedy of equal 
efficacy with opium, and I doubt very much 
whether any medicine will ever be discover- 
ed, operating with equal power in alleviating 
pain, allaying action, and inducing sleep. Its 
sedative powers are fully confirmed by the ex- 
perience *of ages. Yet it is by no means ap- 
plicable in every case, or in every constitution 
where sedatives are required. For some time 
past, I have also often with great advantage 
employed lactucatium, or lettuce opium, as 
it has been called, from its very great resem- 
blance to opium obtained from the papaver 
somniferum. I have found it, in particular, 
a very efficacious means of alleviating pains, 
and procuring sleep in the night, to some rheu- 
matic patients, who, if they had taken opium, 
would, during the course of next day, have 
been subjected to great sickness at the sto- 
mach, and other distressing symptoms. 

Edinburgh, 
Oct, 20, 18it>. 



X.K. 



CONTENTS. 



- 



Page 
Ixtroductiox, respecting the different species into which 
Pulmonary Consumption ob Phthisis may be divided 1 

CHAP. I. — Description of the Pneumonic Symptoms in Catar- 
rhal Phthisis - - - - - 7 

CHAP. II. — -Description of the Pneumonic Symptoms in 
Apostematous Phthisis - - - - 14 

CHAP. III. — Description of the Pneumonic Symptoms in Tu- 
berculous Phthisis ----- 22 

CPAP. IV. — Observations on the Hectic Fever attending 
Phthisis ...... 28 

CHAP. V. — Observations on the symptoms in the Last Stage 
of Phthisis ...... 37 

CHAP. VI. — Observations on the Diagnosis in cases of 
Phthisis - - - - - - 46 

CHAP. VII. — Observations on the general plan of Cure in 
Phthisis _--.._ 58 

CHAP. VIII. — Observations on particular Practices empwyed 
in Phthisis, recommended by Eminent Writers, - 66 

Appendix - -• - - 131. 



OBSERVATIONS 



tfN 



PULMONARY CONSUMPTION, 



INTRODUCTION, 



OF all the diseases to which the inhabitants of the 
British Isles are frequently subjected, Pulmonary Con- 
sumption, or Phthisis Pulmonalis, as it is denominated 
by the best medical writers, may justly be reckoned 
one of the most fatal. The deaths which it occasions 
happen chiefly to those who have arrived at the most 
engaging period of life, the period of youth. Hence 
they are most deplorable. It is not therefore wonder- 
ful, that this disease should have claimed particular 
attention from the most eminent medical writers. But 
notwithstanding the study and labour of ingenious and 

A 



INTRODUCTION. 



discerning men for many ages, plrfliisis pulmcmaKs still 
continues to be an opprobrium to the healing art; and 
the prospect of wiping oif this opprobrium, by com- 
municating to the public a successful method of cure, 
is not great. There is no reason, however, to despair 
of making some progress in this important object; 
and if medical practitioners were enabled to distin- 
guish the different modifications under which this dis- 
ease appears, at its commencement much good might be 
done. For in the earliest stages, the best chance is 
at least afforded of combating this dangerous disease. 

The following remarks on that interesting subject 
are the result of observations made with fidelity and 
attention for more than half a century- And if they 
shall enable future writers to improve the means of 
distinguishing the different modifications of Pulmona- 
ry Consumption from each other, they may be produc- 
tive of some benefit to mankind; and I am convinced, 
that, in some instances of this disease, they will be 
the means of accomplishing a cure. By proper 
treatment, adapted to each particular modification from 
an early period of the disease, there can be no doubt 
that many valuable lives maybe saved. 

hf Phthisis Puhnonalis, or Pulmonary Consumption, 
is to be understood that affection in which a genera] 



INTRODUCTION, 3 

wasting or consumption of the body arises from a dis- 
ease of the lungs. Among eminent writers, it has 
been a subject of dispute whether phthisis pulmonalis 
can ever be considered as a proper idiopathic disease. 
By many it has been regarded merely as symptomatic 
of other affections, particularly of haemoptysis, ca- 
tarrh, scrofula, pneumonia, and several other genera. 
But there can, I think, be no doubt that it may justly 
be considered as an important genus by itself; and that 
it not unfrequentiy makes its approaches in such a gra- 
dual and imperceptible manner, as to be beyond the 
power of art, before it be certainly discovered to exist. 

In every instance of this affection, that modification 
of fever, which has been termed Hectic Fever, is ob- 
served some time before a fatal conclusion takes place. 
And this fever principally, perhaps even solely, arises 
;.Vom the absorption of purulent matter, or rather from 
the absorption of a sanious or vitiated purulent matter, 
which produces in the human system effects much more 
deleterious than the absorption of mild pus, void of 
any peculiar fuetor, or other strong 'sensijjj! qualities. 
Such a sanious matter, however, when generated in the 
lungs, may be afforded from -different causes. Hence, 
among those writers who have considered phthisis or 
tabes pulmonalis as a generic disease, that genus has 
been divided into many different species. In the Sys- 



* INTRODUCTION. 

tern of Sauvages, twenty species are enumerated un- 
der this genus. But from such minute subdivisions, 
no benefit and much inconvenience arise. Hectic 
fever, indeed, produced by purulent matter absorbed 
from the lungs, may arise from many different acci- 
dents, and from many different diseases: And thus it 
cannot be denied, that there is a foundation for many 
different species of phthisis. But after, in these cases, 
consumption is induced, such species can neither be dis- 
tinguished from each other by the symptoms, nor do 
they require a different mode of cure. A more sim- 
ple view, therefore, of the divisions of this genus, may 
be taken with advantage. 

In the division of any genus of disease into spe- 
cies, two great objects are to be had in view. The 
first and principal object is to point out such species 
as require a different mode of practice from each 
other. And the second object is to point out those spe- 
cies which can be distinguished from each other by ob- 
vious symptoms during the life of the patient. The 
distinction from each other, of species which can be 
discovered only by dissection after death, serves mere- 
ly to perplex and puzzle, without being of any material 
benefit. On this general ground, and with these ob^ 
jects in view, in pulmonary consumption, three different 
species may be pointed out, which may not only be d 



INTRODUCTION. O 

anguished by obvious symptoms during the life of the 
patient, but which also require considerable difference 
in that mode of treatment best fitted for the removal 
of each. 

These species may, I think, be denominated the 
- Catarrhal, the Jlpostematous, and the Tuberculous 
Phthisis. The principal circumstance in which these 
species differ, and which necessarily requires variety in 
the mode of treatment, is the difference in the source 
from whence the purulent matter is derived. In the 
first modification, it is merely separated from an in- 
flamed surface, in a manner similar to the separation 
of pus from a blister-issue. In the second modifica- 
tion, it is furnished from an abscess of a considerable 
size, which may be formed in the cellular substance of 
the lungs, as well as of any other part of the human 
body. In the third, it is furnished from a tubercle, or 
from the parts surrounding a tubercle, terminating in 
suppuration; and commonly yielding, not proper puru- 
lent matter, but rather an ichorous sanies, somewhat 
resembling that which is often yielded by lymphatic 
glands, in cases of scrofula, when scrophulous tumours 
terminate in suppuration. But the distinction of each 
of these modifications, during the life of the patient, can 
only be drawn from an accurate account of the symp- 
toms with which they are commonly attended, ^.nd 
a 2 



« 3NTR0DUGTI0N- 

with that intention, a short history of each is sub- 
joined. 

In every modification of phthisis, the symptoms may 
be referred to three heads: the pneumonic, or pulmo- 
nary symptoms; the symptoms of hectic fever; and the 
supervening affections, or what may be termed the con- 
sequent symptoms. The morbid affections, however, 
referable to the two last heads, are very much the same 
in all the species mentioned above. The hectic fever 
in particular, though most exquisite in tuberculous 
phthisis, is an essential attendant of all the three; and 
it is always principally, often entirely, in the pulmo- 
nary symptoms, that the three species obviously differ 
from each other. In describing these affections, then, 
with a view to the diagnosis, it will be sufficient to 
give a separate account of the pneumonic symptoms 
occurring in each different modification of pulmonary 
consumption which has been mentioned. 



CHAPTER I. 

DESCRIPTION OF THE PNEUMONIC SYMPTOMS OCCURRING 
IN CATARRHAL PHTHISIS. 

This modification of Phthisis generally begins in 
a manner very similar to ordinary catarrh, arising 
from accidental exposure to cold. But after the peri- 
od at which that affection may be expected to decline, 
some symptoms are observed to increase. The cough 
becomes very severe through the day; but is generally 
remarked to be much aggravated on first going to bed. 
The patient becomes affected with some degree of 
dyspnoea, even when in an erect posture; but this is 
commonly increased by a horizontal position. In 
general it is not particularly increased by lying on one 
side more than on the other, and the patient sleeps with 
equal ease on either side. He is not affected with 
any fixed or constant pain at the breast. But he com- 
plains of a general sense of soreness in the thorax, and 
not unfrequently he is affected with pretty severe^ 



8 SYMPTOMS OCCURRING 

though transitory pains, sometimes in one side,^ome 
times in the other. 



With the continuance of these symptoms, a change 
takes place in the appearance of the matter expectorat- 
ed. The expectoration, as is commonly indeed the 
case in catarrh, when degenerating into its chronic 
state, becomes of a white or yellow colour. But it does 
not acq aire that remarkable degree of viscidity which 
is the characteristic of thickened mucus. It is soon 
observed to have a peculiar disagreeable taste and 
smell. The odour which it emits becomes somewhat 
fetid, particularly upon being burnt in the fire. These 
changes, however, in the sensible qualities of the mat- 
ter expectorated, are by no means such as to give cer- 
tain evidence of its being of a purulent nature. 

In most instances, there is no appearance of blood 
in the matter expectorated. If blood does appear, it 
is only in streaks, and is merely accidental, adhering 
to the expectorated matter without any intimate union, 
and arising from the rupture of some small superficial 
vessel. The expectorated matter itself has an uni- 
form appearance; yet there is good reason to conclude, 
that it is a mixture of pus and mucus. This appears 
from adding it to water. It will often be found, that, 
in a short time, a considerable portion of it sinks to 
the bottom of water in a less tenacious form than that 



IN CATARRHAL PHTHISIS. V 

portion which swims on the surface; and where such 
a separation does not spontaneously take place, it may 
frequently be affected by agitation in the water. 

In some cases, without any spontaneous separation, 
the whole of the expectorated matter will be suspended 
in the middle of the water in a pyramidal shape, and 
can neither be properly said to sink nor to swim. 
Where a portion of the expectorated matter sinks to 
the bottom of the water, there can be little doubt, 
that it contains pus as well as mucus ; but when it 
neither sinks nor swims, and cannot be separated by 
agitation, there is room for hesitating respecting its 
contents. And if a determination cannot be formed 
from its specific gravity, we can as little form a cer- 
tain judgment from its colour, consistence, and smell. 
For in all these particulars, pure mucus may have a 
very exact resemblance to a mixture of pus and mucus* 

Such, however, is the difference of treatment requi- 
site in every species of phthisis, from that which is 
proper in catarrh, that it is of great importance to de- 
termine, whether the expectorated matter does really 
contain any pus or not. For this is the chief circum- 
stance, by which, before the occurrence of distinctly 
marked hectic fever, the presence of catarrhal phthisis 
can be determined, 



10 SYMPTOMS OCCURRING 

Besides the tests of purulence, therefore, which are 
afforded by the appearance of the matter expectorated, 
by the smell, and by immersing it in water, other and 
more certain tests have been sought for; and inquiries 
on this subject, if they have not led to certainty, have 
at. least done something. 

An experimental investigation of a proper chemical 
test, for distinguishing pus from mucus, when discharg- 
ed from the lungs by expectoration, was proposed as 
the subject of a prize question, by the Harveian So- 
ciety of Edinburgh, in the year 1777. On that occa- 
sion the prize was adjudged to a Dissertation written 
by a very able and ingenious young man, Mr Charles 
Darwin, son to the celebrated author of the Zoono- 
mia. By the untimely death of that excellent youth 
he was prevented from prosecuting his discoveries, or 
from publishing to the world what he had discovered. 
But Dr Erasmus Darwin, after the death of his son 
Ch.lree5. published an account of these experiments, 
as well as some other manuscripts which the young 
mau had himself intended for publication. Without 
entering minutely into the subject, it may be sufficient 
to observe, that Mr. Darwin drew from his experi- 
ments the following conclusions. 

1. Pus and mucus are boch soluble in sulphuric 



IN CATARRHAL PHTHISIS. II 

acid, although in very different proportions, pus being 
by far least soluble. 

%. The addition of water to either of these solutions 
decomposes it. The mucus thus separated either 
swims on the top of the mixture, or forms large floe- 
euli suspended in it; whereas the pus- falls to the bot- 
tom, and forms, on agitation, an uniform turbid mixture. 

3. Pus is diffusible through diluted sulphuric acid, 
though mucus is not. And the same also occurs with 
water, or a solution of sea-salt. 

£ 

4. Nitrous acid dissolves both pus and mucus. 
Water added to the solution of pus produces a preci- 
pitate, and the fluid above becomes clear and green; 
while water and the solution of mucus form a turbid 
dirty-coloured fluid. 

5. Alkaline lixivium dissolves, though sometimes 
with difficulty, mucus, and generally pus. 

6. Water precipitates pus from such a mixture, but 
does not precipitate mucus. 

7. Where alkaline lixivium does not dissolve pus, 
it still distinguishes it from mucus, as \\ then prevents 
its diffusion through water. 




12 SYMPTOMS OCCUPYING 

8. Coagulated lymph is neither soluble in concen- 
trated nor diluted sulphuric acid. 

9. Water produces no change on a solution of serum 
in alkaline lixivium, until after long standing, and then 
only a very slight sediment appears. 

10. Corrosive sublimate coagulates mucus, but does 
not coagulate pus. 

If these conclusions be well founded, and if they hold 
at least generally, although not universally, it appears, 
that strong sulphuric aci-i and water, that diluted sulphu- 
ric acid, and that caustic alkaline lixivium and water 
will serve to distinguish pus from mucus; that the sul- 
phuric acid can distinguish it from coagulable lymph; and 
the alkaline lixivium from serum. When, therefore, any 
one entertains doubts about the composition of expec- 
torated matter, let him dissolve it in sulphuric acid, 
and in caustic alkaline lixivium, or the aqua potassae, 
as it is now styled in the Edinburgh Pharmacopeia. 
Let him then add pure water to both solutions. If 
there be a precipitation in each, he may be assured 
that some pus is present. But if there be a precipitation 
in neither, it is a certain test, that the expectorated 
matter consists entirelv of mucus. 



m CATARRHAL PHTHISIS. 13 

These are, perhaps, the best criteria yet discovered 
for ascertaining whether expectorated matter does or 
does not contain a mixture of pus. Where it is found 
to be merely mucus, we may safely conclude, that 
the disease is entirely catarrhal; but where a mixture 
of purulence, though to a small extent only, is detect- 
ed, we may conclude that it is an incipient phthisis, 
even although no symptoms of hectic fever have yet 
taken place, or have not been obviously observed. 



14 



CHAPTER II. 

DESCRIPTION OF THE PNEUMONIC SYMPTOMS OCCUR* 
RING IN THE APOSTEMATOUS PHTHISI6. 

That modification d? pulmonary consumption 
which may be termed the Apostematous, and which 
immediately arises from a large abscess formed within 
the thorax, is more distinctly marked than the catar- 
rhal phthisis. It is a less frequent disease than the catar- 
rhal; but when occurring, it is more generally fatal. 

The former, as has already been observed, is very 
commonly ushered in by cough, with copious expecto- 
ration, and is almost universally excited by the action 
of external cold, or rather of sudden transitions from 
heat to cold. To these transitions the human species 
are perhaps more exposed in Britain than in any other 
country. The present species of phthisis, again, 
which depends upon a large apostema within the chest, 
may be excited by a variety of different causes. It 
may be produced by any accident giving rise to an in- 



APOSTEMATOUS PHTHISIS. Jc 

lammatory affection, either in the lungs, op in those 
membranes by which they are surrounded; and an in- 
flammation of the thoracic viscera, terminating in a 
state of suppuration, is perhaps as frequent as a simi- 
lar termination from the inflammation of any other parte 

One of the most frequent causes from which an ab- 
scess in the chest derives its origin, is an haemorrhage 
taking place from the lungs. This, indeed, is so much 
the case, that Dr Cullen, in his Nosological System, 
has not considered phthisis as a proper genus of dis- 
ease, but has merely ranked it under the genus of hae- 
moptysis, and viewed it as a sequela of that affection. 
But this I am inclined to consider as a very erroneous 
view of one of the most important genera of disease 
to which the hitman body is subjected. 

That, however, the apostematous phthisis often be- 
gins with a profuse spitting of blood, is unquestionable. 
Haemorrhage, when occurring from the lungs, as well 
as from other parts of the system, may be either of the 
active or passive kind. Boih these modifications of 1 
haemorrhage, when occurring even to a great degree, 
have not unfrequently a speedy termination, without 
any bad consequence; or at least without producing 
phthisis. As well as the vessels of the nose in epistax- 
is, those of the lungs, when ruptured, may be healed 



16 PNEUMONIC SYMPTOMS 

by the first intention. Nay, haemorrhage from the 
lungs, as well as from the nose, may sometimes be 
even salutary, by removing a plethoric state. Yet, in 
many instances, both active and passive haemorrhage 
from the lungs terminates in that species of inflamma- 
tion, which has been termed the suppurative; and this 
more frequently happens as a consequence of haemor- 
rhage from the lungs, than from any other part of the 
body, probably in consequence of that constant state 
of motion to which the lungs are subjected in respira- 
tion. Haemoptysis, then, may justly be esteemed one of 
the chief causes from which a large vomica or aposte- 
ma in the lungs derives its origin. 

But it is by no means the only source of the apos- 
tematous phthisis. Even larger abscesses than those 
commonly arising from haemorrhage are not unfre- 
quently observed from other causes. The lungs them- 
selves, and the membranes by which they are surround- 
ed, it is well known, are frequently subjected to a 
state of active inflammation; and inflammation in 
this, as well as in other parts of the system, may ter- 
minate in a state of suppuration. Thus, apostematous 
phthisis may be induced from several genera, referred 
to the order of phlegmasia, which affect the lungs; 
from pkuritis, peripneumonia, or suppurative inflam- 
mation from odier diseases of the lungs. 



SN APOSTEMATOUS phthisis. IK 

Besides these genera of disease, suppurative inflam« 
mation, giving rise to a large abscess within the chest, 
may proceed from accidental injuries to that part 
of the body. Thus, a large apostema in the lungs 
may be the consequence of a severe blow received 
upon the chest, or a wound of the lungs from a sword, 
a bullet, or the like. Many other causes might also be 
enumerated, as at times producing an abscess of the 
lungs. But the particular causes by which such ab- 
scesses are commonly produced, may be referred to one 
of the three general heads already mentioned, haemor- 
rhage, phlegmasia, or injury to the breast. 

When, from any particular cause, an apostema is 
formed in the lungs, those pneumonic symptoms with 
which it is attended are in several respects very dif- 
ferent from the pneumonic symptoms which occur in the 
catarrhal phthisis; and in the apostematous phthisis, 
the pneumonic symptoms are very different before the 
rupture of the abscess, from what they are afterwards. 

In most instances of the apostematous phthisis, the 
first symptom of the affection is a fixed pain of the 
breast. This pain is not indeed in general excruciat- 
ing; but it is almost constantly felt to some degree, and 
is commonly referred to some one particular spot. For 
fhe most part, it is rather a gravative than an acute 

B % 



lb P>*EUMO>*IC SYMPTOM? 

pain; but it is not unfrequently of the pulsating kind 
Whatever the nature of the pain may be, it is very com- 
monly attended with some degree of dyspnoea. With that 
dyspnoea the patient is sensibly affected, even when in an 
erect posture: but it is in general much increased in a 
horizontal position; and it is often particularly aggravat- 
ed when the patient lies on one side rather than the other 
Often it happens that the patient can breathe only 
"when he lies on that side in which the apostema is situ- 
ated; the reason of which is abundantly obvious. 

With this state of respiration, there occur frequent 
and severe fits of coughing; but for some time tl. 
are attended with very little or even no expectoration, 
In this, then, there is a manife 
catarrhal and apostematous phthisis: For the former 
is from the beginning attended with copk . ora- 

tion; but in the latter species, the most remarkable ap- 
pearances are those which occur on the bursting of the 
3postema. This event is generally preceded, or at 
least attended, by a slight degree of bloody expectora- 
tion, probably arising from a rupture of the v 
the integuments. When this occurs, it is almost im- 
mediately succeeded by a copious 'discharge of pure 
purulent matter. This pus is sometimes coughed up 
at once, to the extent of several oui: ; 
apostema is very large, even of several pour. 



IN APOSTEMATOUS PftfHlSlS" 19 

much, that it not unfrequently threatens, and has some- 
times even given rise to suffocation. 

The matter thus discharged has the same appear- 
ance, the same smell, and other sensible qualities 
which are observed in pus, when it is discharged by 
opening a large abscess situated on any part of the 
surface; and although it be discharged by coughing 
from the lungs, it is in general without any mixture of 
mucus. Hence, by the simple test of sinking in water, 
as well as by the smell and taste of the patient by 
whom it is expectorated, it may readily be distinguish- 
ed from the mixture of purulent and mucaginous matter 
expectorated in catarrhal phthisis. 

After the first copious discharge ensuing on the im- 
mediate rupture of the apostema, the preceding symp- 
toms are commonly somewhat alleviated. This is 
particularly the case with respect to the pain of the 
side and dyspnoea. The gravative or pulsating pain, 
referred to a particular spot of the breast, is in general 
much diminished. The dyspnoea also is much allevi- 
ated; and after a copious discharge, the patient finds 
that he can breathe with equal ease when lying on 
either side. 

Often, also, soon after the rupture of an apostema in 



20 PNEUMONIC SYMPTOMS 

the lungs, the cough becomes much less severe than 
formerh : For, although the fits of coughing may be 
more frequent, yet they are no longer fruitless efforts, 
bat are sooner terminated by free expectoration. Still, 
however, there is in general, for some time after the 
rupture of the vomica, a discharge, in consequence of 
coughing, of the same matter as when the rupture first 
took place. But in no long time, the matter expecto- 
rated has less the appearance of pure pus. It acquires 
a thinner consistence, and not unfrequently a reddish 
tinct. When this last occurs, it may always be con- 
sidered as arising from some mixture of blood. 

After the expectoration arrives at this state, the hec- 
tic symptoms, if they had not before taken place, art- 
soon observed; or, if they were before obvious, they 
are soon much aggravated. 

From a free discharge of the pnrulent matter, even 
after a considerable degree of hectic fever has taken 
place, some chance is certainly afforded of the healing 
of the ulceration, and the recovery of the patient. But 
more frequently, from an increase of the hectic fever, 
and from what may be called its consequent symp- 
toms, colliquative sweats, colliquative diarrhoea, and 
the like, this modification of phthisis has a fatal termi- 
nation. 



IN APOSTEMATOUS PHTHISIS. 21 

Distinctly marked apostematous phthisis may some- 
limes occur, where the purulent matter cannot be con- 
sidered as formed in the lungs, but where, in conse* 
quence of preternatural adhesion and rupture, it has 
made its way from the liver to the lungs. A very re- 
markable instance of this modification of apostema- 
tous phthisis, from which a complete recovery took 
place, occurred in a son of mine, an officer in the ser- 
vice of the Honourable East India Company in Bengal, 
During his illness, he lived in the house of Dr Alex- 
ander Campbell, at that time Secretary to the Medi- 
cal Board at Calcutta, and was attended also by Dr 
Francis Balfouj*, then at the head of the Medical 
Board. From both these gentlemen, since their return 
to Britain, I have had very accurate accounts of his 
disease. But I shall only at present observe, that the 
purulent matter, expectorated in great quantities from 
the lungs, was indubitably formed in the liver ; that, 
notwithstanding the formidable appearance of his com- 
plaint, and the diseased state to which both the lungs 
and liver were subjected, he had a complete reco- 
very without finding it necessary to return to Britain; 
and that lie has since been the father of a numerous 
family of healthful children born in India, 



22 



CHAPTER III. 

'DESCRIPTION OF THE PNEUMONIC SYMPTOMS OCCURRING 
IN THE TUBERCULOUS PHTHISIS. 

Of all the species of phthisis, the Tuberculous is 
both the most frequent and the most dangerous. That 
it should be the most frequent is, p§rhaps, in some de- 
gree, the consequence of its arising from the greatest 
variety of exciting causes. But however numerous 
and varied these exciting causes may be, all of them 
operate as giving rise to this modification of phthisis 
on one general principle, viz. as inducing those pecu- 
liar tumours termed tubercles, which have been 
found in the lungs of patients who have died of this 
modification of phthisis. 

The appearance of these tumours has been accu- 
rately described by several eminent writers on morbid 
anatomy. Here, it is sufficient to observe, that they 
are in general found under the form of hard substances, 
which, when cut, appear to be solid bodies of a whitish 



TUBERCULOUS PHTHISIS. Z6 

colour. Respecting their nature, different opinions 
have been entertained. Some suppose them to be 
entirely inorganic bodies, formed of the coagulable 
part of the circulating blood. And that they are often 
incapable of being penetrated even by the finest injec- 
tions, is certainly true. But a more common opinion 
is, that each tubercle may be considered as a lympha- 
tic gland in a particularly diseased state; that this 
diseased condition is the consequence of scrofula; and 
that the tuberculous phthisis may in every instance be 
considered as scrofula affecting the lungs. 

In support of this doctrine, there are many probable 
arguments; and, among other things, this opinion is 
corroborated, from its being a well known fact, that 
tuberculous phthisis is often observed as a hereditary 
disease in scrofulous families; from its occurring most 
frequently at a particular period of life, between the 
age of fifteen and twenty-five; and from the striking 
resemblance which may often be observed between 
tubercles of the lungs and diseased mesenteric glands, 
producing tabes or phthisis mesenterica in those who 
are evidently subjected to hereditary scrofula: For in 
the mesentery, the diseased tubercles, though they 
were unquestionably at first lymphatic or lacteal glands, 
are equally inorganic as tubercles of the lungs. But, 
without offering at present any further observations on 



24 PNEUMONIC SFMPTOMS 

the nature of those tumours which give rise to that 
modification of phthisis which may be denominated 
the Tuberculous, I shall proceed briefly to describe the 
symptoms with which it is commonly attended. 

Of all the modifications of phthisis, the pneumo- 
nic complaints which occur in the tuberculous are 
| the least alarming. Hence, this species often subsists 
for a considerable time before it awakens the attention 
of the patient. This the rather happens, because the 
fever with which the tuberculous phthisis is attended 
at its commencement is in general accompanied with 
high spirits. And from this state of exhilaration, even 
to the latest periods of the disease, patients affected 
with tuberculous phthisis have often no apprehension 
of their own danger, though approaching death be 
manifest to every spectator. 

At the commencement of tuberculous phthisis, nei- 
ther the cough uor dyspnoea are by any means ur- 
gent; and in many instances, even to the very end of 
the affection, there hardly occurs any expectoration. 
The cough, in general, is of the short tickling kind, 
without being violent, and may be termed rather a tus- 
sicula than a tussis. But while it takes place without 
any great uneasiness, it is still troublesome, from being 
very frequent. Notwithstanding, however, these fire- 



IN TUBERCULOUS PHTHISIS. 25 

♦]ueiUly repeated efforts towards expectoration, the irri- 
tating cause is not removed, and those* slight fits of 
coughing, terminating without the smallest expectora- 
tion even of mucus, are again speedily renewed. 

In most cases no remarkable pain of breast attends 
the tuberculous phthisis; and when pain occurs, it is 
neither fixed to any particular spot, nor is it constant. 

In many instances, no dyspnoea whatever occurs in 
the tuberculous phthisis; or, at least, difficulty of breath- 
ing is observed only upon motion or exertion. When 
the patient remains at rest, the breathing is perfectly 
free; and it is very little if at all affected by change in 
the position of the body. Contrary to what happens 
in the apostematous phthisis, the patient can lie with 
equal ease on either side. 

In this state of the pneumonic complaints they very 
seldom alarm the patient. And if they give any alarm 
to others, it is only in general from their long continu- 
ance, and from their occurring in habits with whom 
there is reason to suspect predisposition to phthisis. 
That this tussicula is the first stage of tuberculous con- 
sumption, is chiefly inferred from the remarkable loss 
of strength, and evident wasting of the habit, with 
which it is soon attended. 



2t> PNEUMONIC SYMPTOxMS 

In the incipient state of the tuberculous phthisis, 
this frequent tickling cough is in general also accompa- 
nied with a peculiar change in -the appearance of the 
eyes. The red vessels which are observable in the 
tunica adnata of those in a state of health, are no longer 
obvious, and that part of the eye obtains very much the 
colour and appearance of a pearl. 

To these slight pneumonic symptoms, even without 
the occurrence of any expectoration whatever, either 
purulent or mucaginous, distinctly marked hectic fever 
often supervenes. In ether cases, however, after the 
cough has been long dry, as it is called, some degree of 
expectoration occurs. But in almost no instance has 
it the appearance either of proper purulent matter or of 
blood. Sometimes a slight tinct of blood is observed; 
but never such a degree of haemoptysis as is often ob- 
served to precede apostematous phthisis. Most fre- 
quently, the matter expectorated is a thin watery fluid 
slightly tinged with blood; and it has very much the 
appearance of that sanies which is often discharged 
from scrofulous sores. When this state of expectora- 
tion takes place, hectic fever is seldom wanting to a 
great degree, and it soon assumes that form which has 
been denominated the Hcctica Exquisita, in contradis- 
tinction to the chronic form, which that modification of 
fever most frequently assumes. 



IN TUBERCULOUS PHTHISIS- 



27 



After having thus briefly described the pneumonic 
symptoms in each of the three different species of phthi- 
sis pulmonalis, we shall next proceed to give some ac- 
count of the hectic fever which may be considered as 
common to all the species. 



CHAPTER IV. 

OBSERVATIONS ON THE HECTIC FEVER IN PHTHISIS 
PULMONALIS, ATTENDING THE SECONB STAGE OF 
THE DISEASE. 

The hectic fever, which attends every species of 
pulmonary consumption, particularly those three spe- 
cies which have been now described, has very much 
the same appearance in all of them; and, indeed, symp- 
toms nearly similar attend hectic fever, when con- 
sumption or tabes arises from suppuration occurring 
not in the lungs, but in other parts of the body, and 
yielding ill-conditioned pus. 

Although several opinions, differing very much from 
each other, have been entertained by able pathologists 
respecting the cause of hectic fever, yet the most pro- 
bable conjecture is, that in all these cases, it is the 
consequence of ill-conditioned pus being absorbed by 



PHTHISIS PULMONALE. 29 

the valvular lymphatics, and thus introduced into the 
mass of blood. It must, however, be allowed, that, 
with respect to the operation of this cause, all practi- 
tioners are not agreed. Some contend, that it arises 
merely from a certain irritable state of the system, in- 
duced by the absorption of pus. But still, even accord- 
ing to this hypothesis, hectic fever is ultimately an ef- 
fect of absorption. And when we consider the influ- 
ence of certain articles introduced into the circulating 
system, in immediately inducing fever, there is great 
reason for presuming, that absorbed ichorous matter 
may immediately give rise. to hectic symptoms. 

Of this a strong presumption is afforded, from experi- 
ments which have lately been made, by injecting dif- 
ferent fluids into the blood-vessels of living animals. 
It has been found, that small quantities of milk, and 
other bland fluids, may thus be injected without any 
inconvenience. But it has also been found, particular- 
ly in the trials which have been made de chirurgia in- 
fusoria renovanda, that the injection, even of smaJI 
quantities, of acrid fluids, such as an infusion of senna, 
a decoction of guaiac, or the like, have the effect of ex- 
citing fever in a very short time. Without entering 
into the consideration of conjectures as to the imme- 
diate cause of hectic fever in pulmonary consumption^ 
it is sufficient to observe, that it often follows the dis* 

C & 



30 HECTIC FEVE!t 

charge of purulent matter by expectoration, particular 
ly when that matter, in place of appearing under the 
form of mild thick white pus, assumes more the ap- 
pearance of a bloody sanies. 

The hectic fever is very generally not of a continued 
form, but consists of repeated paroxysms; or at least, 
although quickness of pulse, and some other febrile- 
symptoms, may be constant, yet, in this fever, there 
are very remarkable remissions and exacerbations. 
These exacerbations are very generally ushered in by 
a sense of coldness; often even to such a degree as to 
induce shivering. It is however but seldom that the 
cold stage in the hectic paroxysm arises to the same 
height as in proper intermittents; and in most in- 
stances it is rather a partial than a general sense of 
coldness; that sensation being more especially felt at 
particular parts, as in the hands, the feet, or along the 
course of the spine. But, even in these places, hew- 
ever disagreeable the sensation may be, there merely 
takes place a sense of coldness, without any real cold: 
For when the parts to which this sensation is referred, 
are accurately examined by the thermometer, they 
are found still to possess the natural degree of heat. 

To this coldness or shivering, a sense of increased 
heat soon succeeds. This sensation is very common- 



IN PHTHISIS PULMONALE. 3* 

\y in some degree extended over the whole body. 
But it is also more especially felt at particular places, 
Often there occurs a peculiar glowing heat in the face; 
and this is commonly attended with manifest flushing 
of the countenance. This redness, however, is not 
always general, but is frequently under the form of a 
circumscribed redness in the most prominent parts of 
the cheek. 

If the heat be sometimes partially increased in the 
face, it is often still more so in other parts of the 
body. This is particularly felt in the palms of the 
hands, and in the soles of the feet' r but notwithstand- 
ing the sensation of heat in these parts, even when it 
is almost intolerable, there is still no obvious redness, 
nor indeed any change of appearance, in the part to 
which it is referred. It consists merely in a sense of 
burning heat, often attended with a parched state of 
the skin at the part thus affected, 

With the augmentation of heat, there is also veny 
commonly an increase of the celerity of the pulse dur- 
ing the hectic paroxysm; and sometimes it is so quick 
that it can hardly be accurately numbered. But m 
many cases, it is not much more accelerated during 
the paroxysm than during the remission. For after 
the commencement of the hectic state, the pulse witk 



3& HECTIC FEVER 

most patients is considerably quicker than it was be- 
fore, seldom being observed under 100, and frequently 
above 120 strokes in the minute. This want of com- 
plete apyrexia often affords a diagnosis between hectic 
and quotidian intermittent fever. For in all the intermit- 
tents, the pulse in the intervals between paroxysms 
returns to the natural standard. 

In some instances of hectic fever, the pulse is full 
and soft. But more frequently it is small and hard 
both during the paroxysm and also during the inter- 
mission. f 

Another circumstance commonly attending the hec- 
tic paroxysm is some degree of thrist; but it is seldom 
that this symptom is considerable. Thirst almost 
never takes place to the same degree as in other mo- 
difications of fever; and in very few cases is the 
tongue either parched, or covered with indurated mu- 
cus, giving what is called a furred tongue. In gene- 
ral, during the whole course of the disease, even during 
the time when the paroxysm is most severe, it con- 
tinues moist. It has in many cases an uncommonly 
slean and red appearance: And in the last stages of 
the disease, it is often found in an abraded and even 
in an ulcerated state. But this appearance may be 
considered as unconnected with the fever itself, an4 



IN PHTHISIS PULMONALIS. $3 

probably in general arises from the condition of the 
matter discharged by expectoration. But as the tongue 
is very rarely observed to be parched, so the thirst is 
seldom augmented to any considerable degree. 

While the thirst in hectic fever is in general not very 
considerable, it has also been remarked, that the appe- 
tite for solid food is rarely so much diminished as in 
other fevers; and sometimes, even in the very last 
stages of the disease, when the hectic symptoms are 
most acute, the appetite is uncommonly keen. Phthisi* 
cal patients have repeatedly been observed to make a 
hearty dinner of beef-stakes a very few hours before 
death, 

Besides the want of thirst, there is also another par- 
ticular in which hectic fever diners from most other 
modifications of that disease. It is without that dis- 
tressing symptom attending most idiopathic fevers, 
which has been termed the anxietas febrUis, — a sen- 
sation which cannot easily be described, but which 
rarely fails to be weir remembered by any one who has 
laboured under idiopathic fever, particularly of the 
typhoid type. So far are hectic patients from being af- 
fected with this febrile anxiety or depression, that they in 
general entertain sanguine hopes of a speedy recovery; 
and during the severity of the paroxysm, they are often 



34 HECTIC FEVER 

observed to have a peculiar flow of spirits, and uncom- 
mon quickness of genius. 

The symptoms thus occurring in the cold and hot 
stages of the hectic paroxysm, in a short time begin to 
subside; and after continuing for a few hours, they of- 
ten terminate without any obvious appearance. This 
is particularly observed to be the case with those pa- 
roxysms which take place about mid-day, or in the 
forenoon, if the patient be not confined to bed. In 
other cases, however, the cold and hot fits of the hectic 
fever are succeeded by sweating, in a manner similar 
to what happens in the intermittent paroxysm. Sweat- 
ing is particularly remarked to occur when the patient 
is in bed during the hectic accession. Accordii 
is a common consequence of those cold and hot fits 
which occur during the night; and, indeed, profuse 
sweating, when the patient first awakes in the morning, 
may be considered as one of the most common symp- 
toms of the hectic fever. 

The urine of patients subjected to hectic fever. 
ticularly what is discharged during or soon after the pa- 
roxysm, is for the most part high coloured. Upon stand- 
ing, there soon occurs a separation of what has been 
termed furfuraccom matter; a matter haviug some re- 
semblance to the bran of wheat. But it seldom hap 



iN PHTHISIS PULMONALIS. 35 

pens that this matter sinks to the bottom of the urine; 
and it is but very rarely that the lateritious sediment of 
the urine, where a matter is deposited resembling brick- 
dust, \rhich is so common after the paroxysm of the in- 
termittent fever, is observed in the hectic fever. 

The discharge by the belly in hectic fever is for the 
most part but little affected. For a long period, in the 
chronic form of this fever, it is not attended with that 
bound state of the belly which is the common concomi- 
tant of other fevers. At least, long after hectic parox- 
ysms have been distinctly observed, the discharge by 
the bowels often continues nearly in the natural state; 
and it is only in the latter stages of the disease that 
the colliquative diarrhoea comes on. Hence, it has been 
called a consequent symptom. 

For the most part, at an early period of phthisis, 
particularly in the tuberculous, the menstrual discharge 
is observed to become very scanty, and often entirely 
to cease. But this is hardly to be considered as parti- 
cularly connected with the hectic fever; and the same 
observation may be made with respect to the remarka- 
ble loss of strength and exhaustion of the habit which 
which occur in the progress of this disease, although it 
must be allowed, that these symptoms always take place 



36 SYMPTOMS IN THE LAST STAGE. 

the most rapidly where the hectic fever is what has bee* 
termed the most exquisite or acute. 

With respect to the recurrence of the paroxysms of 
the hectic fever, the same type has not always been 
observed. By some writers, indeed, the paroxysms 
have been alleged to occur with great regularity twice 
every day; the first attack taking place about noon, 
and the second before midnight, and commonly termi- 
nating with sweating early in the morning. It has 
been more generally observed, that a paroxysm occurs 
after eating, especially after dinner. But the parox- 
ysms of the hectic fever are by no means observed to 
return with the same regularity as in any type of in- 
termittent fever having a daily paroxysm, whether 
quotidian or double tertian. In most instances, one 
accession only is observed in the course of the day. 
In other cases, two, or even three accessions may be 
observed in the same length of time. But these do not 
occur with any regularity, or at any fixed time: And 
they are often distinctly observed to be excited either 
by taking food, or by the action of external cold, at 
whatever period of the day the patient may have been 
'exposed to the action of these causes, particularly of 
cold. 



37 



CHAPTER V. 

OBSERVATIONS ON THE SYMPTOMS OCCURRING IN THE 
LAST STAGE OF PHTHISIS PULMONALIS; WHAT MAY 
BE TERMED THE SUPERVENING OR CONSEQUENT SYMP- 
TOMS. 

After the hectic fever has been observed for some 
time, and particularly if it be of the acute or exquisite 
kind, some symptoms, which had before taken place, 
are very rapidly augmented; and others, which had 
not been observed, supervene. These have, in general, 
been considered as sequelae of the hectic fever. But 
it may, perhaps, be a matter of doubt, whether, with 
strict propriety, they can be called consequent symptoms. 
Perhaps, like the hectic fever itself, they are merely 
symptomatic of the progress of the disease, — of the 
absorption of an ill-conditioned purulent or ichorous 
matter from the lungs. But still the probability is, that 
if not induced, they are at least much aggravated by 
the hectic fever. And whatever their cause may be, 

D 



38 SYMPTOMS IN THE LAST STAGE 

they may certainly be considered as constituting the 
third stage of the disease. 

At the head of the consequent symptoms, as one of 
the most obvious, emaciation or wasting of the habit 
may justly be mentioned. It is indeed true, that, even 
from the beginning of every species of phihisis, the 
usual fulness or plumpness of the patient is somewhat 
diminished. But after the hectic fever has subsisted 
for some time, this emaciation is very much increased. 
It is obvious, on examination of any part of the body. 
It evidently appears from clothes, which were before 
tight, becoming too wide, and it is still more certainly 
demonstrated by the loss of weight. But in no part of 
the body is it more conspicuous than in the face. This 
is so much the case, that the fades Hippocraticcty as it 
has been called, where every bone of the face is pro- 
minent, is, perhaps, more frequently observed in pulmo- 
nary consumption than in any other disease. But 
when the trunk of the body is examined, the state of 
the spine shows projection of the bones to as great a 
degree, in parts remote from the face. In short, in the 
last stage of phthisis the patient often becomes as 
it were a living skeleton. 

In this emaciation, there can be no doubt that there 
occurs a diminution both of fluids and solids; and 



OF PHTHISIS PULMONALIS. 39 

that the loss in some degree extends not merely to the 
softer solids, but even to the firmest and hardest, to the 
bones themselves. But of all the parts of the body, 
there is reason to believe, that this change in appear- 
ance chiefly arises from the consumption of fat; a sub- 
stance which, in the temperature of the human body, 
may be considered as of an intermediate consistence 
between solid and fluid; and a substance which, it is 
well known, readily admits of removal by the valvu- 
lar lymphatic absorbents, after it has been deposited 
in the membrana adiposa in any part of the body. That 
during the course of phthisis pulmonalis much fat is 
removed from the cells of this membrane, and very 
little deposited in them, cannot be doubted. This is 
clearly demonstrated by the dissection of those who 
have died of pulmonary consumption; for it is then 
found that the fat is entirely removed, not only from 
the surface, but also from the interior parts; and hardly 
a vestige of fat is to be found either at any of the 
joints, about the heart, or even in the omentum, parts 
in which it is certainly most necessary for the purpo- 
ses of the animal economy. 

With the emaciation, it cannot at all seem wonderful 
that a state of debility should occur. A loss of muscu- 
lar vigour, as well as evident wasting of the habit, is 
indeed one of the earliest symptoms of phthisis. Those 



40 SYMPTOMS IN THE LAST STAGE 

subjected to any modification of the disease, soon be- 
come incapable of their usual exertions; and after even 
very slight action, they feel an uncommon degree of fa- 
tigue. But this debility rapidly increases in the last 
stage of the disease, and particularly where the hectic 
fever is very acute. The loss of strength is sometimes 
even greater than in proportion to the evident exhaust- 
ion of the body, and might lead to the supposition, that 
in such cases there was a greater absorption from the 
muscles than even from the fat. 

Some writers have considered this debility as the sole 
and primary cause of the disease; aud entirely over- 
looking the obvious morbid affection of the lungs, they 
have placed phthisis at the head of the scale of asthenic 
diseases, as they have termed them, and accordingly 
have inferred, that pulmonary consumption is to be cur- 
ed by the use of stimulants, increasing excitement. But 
this reasoning, though lately a fashionable doctrine, is 
too absurd, and the practice too pernicious, to be adopt- 
ed by any man of common understanding. Debility is a 
necessary consequence of the continuance of almost 
every disease, and must necessarily occur in phthisis 
as well as in others. But it rapidly increases towards 
the last periods of phthisis, when there is reason to be- 
lieve that the circulation has almost every where failed 



OP PHTHISIS PULMONALIS. 41 

in the extreme vessels. It is a consequence not the- 
cause of the disease. 

Of the failure of circulation in the extreme vessels 
in phthisis, evidence is afforded in the appearance of the 
countenance, and particularly in the appearance of the 
eye. It is indeed true, as has already been remarked, 
that in the paroxysm of the hectic fever, a circum- 
scribed redness of the cheek is often observed. But at 
other times there is very generally an uncommon 
paleness of the countenance, and indeed of the surface 
over the whole body, clearly demonstrating a want of 
red blood in the extreme vessels. This also manifest- 
ly appears in that change which the tunica adnata of 
the eye undergoes. In a state of health, some red ves- 
sels are in general obvious in this part of the eye. But 
as phthisis advances, these gradually disappear, and 
the whole of the adnata becomes of a pearly white 
colour. 

Another remarkable appearance which often takes 
place on the surface of the body in phthisis, and which 
is probably also the consequence of want of circulation 
in the extreme vessels, is that the hairs are observed to 
fall off, a necessary consequence cf the want of nou- 
rishment supplied at their bulbs. To a similar want 
of nourishment is probably also to be referred the 
d2 



42 SYMPTOMS IN THE LAST STAGE 

crooked, wreathed, or adunque shape, as it has been 
called, which the nails often assume in the last stage 
of pulmonary consumption. 

To a want of due propulsion of blood to the extreme 
vessels, it is not improbable also that the condition of 
the menstrual discharge commonly attendant on phthisis 
is to be attributed. It must indeed be admitted, that 
in some instances of pulmonary consumption, the men- 
ses continue regular to their periods, and flow in the 
usual quantity to the very last stage of the disease. 
But much more frequently, the discharge is scanty or 
altogether wanting, even from the commencement, 
And from this circumstance, phthisis in its first stages 
is sometimes mistaken for amenorrhoea. But what- 
ever may be the condition of the menstrual flux in the 
beginning of the disease, a total want of this discharge 
in most cases very soon supervenes after the hectic fe- 
ver is distinctly marked. 

When regard is paid to the remarkable loss of 
strength with which phthisis is attended, it is not 
wonderful that towards the close of the disease (ede- 
matous swelling of the legs should often appear. 
This symptom, however, notwithstanding the great 
debility, is neither universal, nor very troublesome. 
And in some cases, after it has taken place to a con- 



OF PHTHISIS PULMONALIS. 43 

siderable degree, notwithstanding the progress of 
phthisis towards a fatal conclusion, and the increase 
of the weakness of the patient, it again decreases,— 
an evident proof that the action of the absorbent ves- 
sels is not so much weakened as that of the muscles 
subservient to voluntary motion. Perhaps also from 
the condition of the circulation, the tendency to 
effusion may be diminished, 

It has already been remarked, that even during the 
accessions of the hectic fever, the tongue is rarel*ob- 
served to be parched. On the contrary, it often as- 
sumes an uncommonly red, and what ma\ be called a 
raw appearance. But the affection of this organ often 
goes farther; and both upon the tongue and other parts 
of the mouth, aphthous spots appear, which in the end 
degenerate into ill-conditioned ulcers. These aphtha 
and consequent ulcerations are particularly observed 
in the apostematous phthisis, when the expectoration 
of purulent matter is considerable, and when, in place 
of the appearance of mild pus, the discharge has de- 
generated into an ichorous state. This affection of 
the mouth has by some been ascribed, and probably 
not without reason, to the action of the expectorated 
matter on the mouth. 

To the same cause, acting on other parts of the 



44 SYMPTOMS IN THE LAST STAGL 

alimentary canal, especially on the intestines, ha? 
been ascribed another symptom, very common and 
very distressing, the colliquative diarrhoea, which 
often occurs in the end of phthisis, and which cer- 
tainly has often very great influence in hastening a 
fatal termination of the disease. That colliquative 
diarrhoea may in some instances arise from purulent 
matter brought from the lungs to the mouth, and after- 
wards swallowed, maybe true. But certain it is, that 
this diarrhoea often takes place where there is no ex- 
pectoration of purulent matter, particularly in cases of 
tuberculous phthisis. Hence, it must often arise from 
some other cause; and perhaps it is with greater jus- 
tice attributed to the influence of absorbed acrid mat- 
ter exerted on the intestines, after entering the blood, 
and to the general debilitated state of the system which 
phthisis induces. But whatever its cause may be, 
there can be no doubt that it is one of the supervening 
symptoms, which contributes very much to bring the 
disease to a fatal termination. 

But of all the supervening symptoms, there is per- 
haps no one which tends more to the rapid exhaustion 
of the patient than the colliquative sweats. These, as 
has already been observed, sometimes occur even at 
an early period of the hectic fever, and are particularly 
observed in the morning, ajter an exacerbation has 



OF PHTHISIS PULMONALIS. 45 

taken place during the night. But they are by no 
means to be considered as similar to those sweats, 
which constitute the third stage of an intermittent pa- 
roxysm. They are by no means productive of the 
same relief from fever. They cannot be said to induce 
- an apyrexia. On the contrary, an evident increase of 
weakness and languor is very generally the conse- 
quence of their being long continued and profuse; and 
this equally happens whether they be extended over 
the whole body, or confined to particular places. 
These colliquative sweats, even when the most pro- 
fuse, are not unfrequently confined to the head and 
shoulders; and when this is the case, the progress of 
the disease to a fatal termination is usually the most 
rapid. 

With these Supervening symptoms, and the continu- 
ance of the hectic fever, it is by no means surprising, 
that the disease, after arriving at this state, should in 
almost every case have a fatal termination. Though 
the mental faculties continue distinct at the commence- 
ment of the hectic fever, yet dilirium of the low kind 
at length necessarily arises, as the consequence of a 
very debilitated state, and is in general a prelude to 
the death of the patient, 



46 



CHAPTER VI. 

•F THE DIAGNOSIS IN PHTHISIS PULMONALIS, 

The diagnosis in cases of phthisis pulmonalis may 
naturally be referred to two heads. First, The means 
of distinguishing phthisis from other diseases ; and, 
Secondly, The means of distinguishing the different 
species of phthisis from each other. 

With regard to the distinction between phthisis and 
©ther diseases, in most cases, at least, there is no great 
difficulty. Although in the beginning of phthisis, there 
is certainly no symptom which can be held forth as 
pathognomonic or peculiar to pulmonary consumption, 
and not occurring in any other affection, yet there are 
different symptoms always attendant on phthisis, 
which in many other diseases are never observed. 
Even in the very earliest stages of this affection, there 
is always more Or less cough; and this cough is verF 
generally attended with some degree both of dyspnoea 



OF THE DIAGNOSIS, &C. 47 

and of pain of breast. Sometimes, indeed, in the 
earliest stages of phthisis, what takes place in the 
way of coughing, may be termed rather tussicula than 
tussis. Still, however, cough exists at least under a 
certain form. Wherever, therefore, cough, with the 
concomitants already mentioned, is entirely awanting, 
it may with certainty be concluded, notwithstanding 
great loss of strength, wasting of the habit, quick- 
ness of pulse, and other hectic symptoms, thai pulmo- 
nary consumption does not occur, and that the tabes or 
phthisis to which the patient is subjected, must pro- 
ceed from some other cause than an affection of the lungs. 

The only difficulty, therefore, of distinguishing be- 
tween phthisis and other diseases, is in those cases 
where cough, with some degree of pain of breast, and 
dyspnoea, takes place. This, however, not unfrequent- 
ly happens in catarrhal affections, the consequence of 
accidental exposure to cold. Catarrh has often many 
symptoms in common with incipient phthisis. But 
this similarity in a particular manner takes place, be- 
tween common catarrh from cold, and that species 
of pulmonary consumption which has been described 
under the title of the catarrhal phthisis. 

In that modification of phthisis, indeed, the disease, 
as has already been remarked, often subsists for a con- 



48 OF THE DIAGNOSIS 

siderable time in a state which may strictly and pro- 
perk be denominated catarrh; and it is only from the 
catarrhus afrigore, that a degeneracy takes place into 
the phthisis catarrhalis. It is therefore by no means 
surprising that cases should occur, in which it is very 
difficult to determine when the catarrh ends, or when 
the phthisis begins. 

With a view, however, of directing the best mode 
of treatment, it is always desirable that a practitioner 
should be able to say with certainty, as soon as possible, 
whether the disease be catarrh or consumption. And 
those marks by which catarrhus a frigore is distin- 
guished from phthisis catarrhalis, with still greater cer- 
tainty serve to distinguish catarrh from other species of 
phthisis. 

Where cough, apparently arising from exposure to 
cold, has subsisted for some length of time, although 
not severe, but merely under the form of tussicula, 
some suspicion may be entertained of phthisis, when 
thai cough comes to be attended with manifest wast- 
ing of the habit, and remarkable loss of strength. 
That these symptoms, indeed, are often the conse- 
quence of mere catarrh, cannot be denied; yet they 
are seldom to the same extent, or make the same rapid 






IN PHTHISIS PULMONALIS. 49 

progress, where the affection continues to be merely 
catarrhal, as when it degenerates into phthisis. 

The suspicion arising from the circumstances that 
have been mentioned, cough combined with wasting of 
the habit, and loss of strength, is much corroborated, 
if the patient be still at an early period of life, particu- 
larly between the age of fifteen and twenty-five: Not a 
indeed, that phthisis may not ensue as a consequence 
of catarrh at other periods of life; but it is chiefly at 
the early and vigorous periods of life that consumption 
is a consequence of catarrh. In advanced life, obsti- 
nate catarrh much more frequently degenerates into 
the chronic state, or what has been called the catar- 
rhus senilis. 

Besides the circumstances which have already been 
mentioned, another ground for distinction between 
phthisis and catarrh is afforded by the state of the 
pulse. In phthisis, quickness of the pulse is a much 
more frequent symptom than in catarrh. This, in- 
deed, can by no means be depended upon by itself; 
nor is it always to be met with at the commencement 
of the disease. In some instances of phthisis, it is only 
an occurrence late in the disease; and in cases of 
. mere catarrh, it not unfrequently takes place, especially 
at the commencement of the disease. But when pre- 

E 



50 dF THE DIAGNOSIS 

iernatural quickness of the pulse continues for a coii- 
siderable time, it is much more frequently observed 
where acute catarrh terminates in phthisis, than when 
it degenerates into the chronic state. 

From these different particulars, in the greatest num- 
ber of cases a diagnosis may be formed, with a con- 
siderable degree of certainty, between phthisis and 
catarrh, even in the early stages of the disease. But, 
when in conjunction with these, it appears, from the 
tests already mentioned, that the matter expectorated 
contains a mixture of pus, there can be no doubt that 
the patient is subjected to pulmonary consumption. 
When to the pulmonary affections hectic fever super- 
venes, and when to these are superadded the consequent 
symptoms, particularly colliquative sweats and colli- 
quative diarrhoea, we have not only certain evidence 
that the patient is subjected to phthisis, but may with 
great probability conclude that the disease will have a 
fatal termination. 

If, however, it be important in practice to distinguish 
phthisis from other diseases; so it is also of conse- 
quence to distinguish the different species of phthisis 
from each other. Three species have been pointed 
out as deserving particular attention, the catarrhal, the 
f apostematous, and the tuberculous: And the following 






IN PHTHISIS PULMONALIS. 51 

observations with regard to each, will point out those 
marks by which they may be most readily distinguished. 

The catarrhal phthisis may occur at any age, 
while the two other species, but particularly the tuber- 
culous, are most frequently observed at a certain period 
of life, between the age of fifteen and twenty-five. 
There is ground, therefore, for suspecting this species 
when symptoms indicating phthisis are observed at that 
period of life, when the other two species are less fre- 
quent. Catarrhal phthisis takes place with any habit; 
while the apostematous is most frequent with the san- 
guine habit, and the tuberculous with those who are 
known to have a scrofulous constitution. Hence some 
ground for distinction is afforded from attending to the 
habit of the patient. 

But if a diagnosis may in some degree be derived 
from predisposition, catarrhal phthisis is still more 
strongly marked by attending to the occasional cause 
by which it is more immediately induced. In most 
instances, this modification of pulmonary consumption 
has its commencement from the obvious action of cold, 
inducing at first a simple catarrhal affection. Thus, 
then, it begins with all the ordinary symptoms of the 
catarrhus a frigore; and in this respect from the com- 
mencement is different from the two other modifications 



52 OF THE DIAGNOSIS 

of phthisis. In a short time, it is distinctly character- 
ized by the state of the cough; for it is soon attended 
with copious expectoration. It is marked also by the 
Mate of pain at the breast. In most instances, the pa- 
tient is not affected with any such pain; and when it 
does occur, it is not confined to any particular part 
The dyspnoea in this species, as well as in the aposte- 
matous, is aggravated by an horizontal posture; but it 
is peculiar to the catarrhal consumption, that the dysp- 
noea is relieved by expectoration, even although only 
to an inconsiderable degree. It is also marked by ano- 
ther circumstance respecting the affection of breathing. 
In this species, the patient, when in an horizontal pos- 
ture, can lie with equal ease on either side. 

While the catarrhal consumption is thus attended 
with many peculiarities, so there are also various symp- 
toms which afford evidence of the apostematous. When 
phthisis evidently occurs, there is some presumption of 
its belonging to this species, where the patient has 
been previously of a vigorous and plethoric habit, par- 
ticularly when with these habits it occurs during the 
prime of life. This presumption is strengthened, if 
there be at the same time no marks of a scrofulous ha- 
bit in the person affected; and if upon due enquiry it 
shall he found, that the patieot has no hereditary dis- 
position to scrofuia, that no scrofula has been observed 



IN PHTHISIS PULMONALE. 5S 

in his family, and that none of his near connexions 
have died of phthisis. There is also reason for 
inferring the existence of this species, where the 
patient has formerly been subjected to active haemor« 
rhage, either from the lungs, or even from the hose. 
This inference may be drawn with still greater 
confidence, where symptoms of phthisis immediately 
succeed to a considerable degree of haemoptysis. And 
there is almost certainty, that the phthisical symptoms 
proceed from an apostema in the chest, when they 
are the immediate consequence of a violent inflamma- 
tory affection of the pneumonic kind. A similar con- 
clusion respecting the species of the disease may also 
be drawn where phthisical symptoms follow soon after 
wounds penetrating into the thorax, blows upon the 
chest, or similar accidents. In short, a considerable 
degree of local inflammation within the chest, from 
whatever cause it arises, may certainly terminate in an 
apostema. 

But besides the ground for diagnosis, which is afford- 
ed by a knowledge of the exciting causes, marks of 
this species are also afforded from the symptoms with 
which it is attended. There is always reason to infer 5 
that phthisis is of the apostematous kind, where the 
patient has long been subjected to fixed pain in the 
breast; where he is affected with -constant dyspnoea, 
e2 



54 OF THE DIAGNOSIS 

even in an erect posture, and where that dyspnoea is 
attended with a sense of weight and oppression at a 
particular part of the breast. This conclusion may 
especially be drawn when the dyspnoea is much in- 
creased by a horizontal posture, and when the patient 
lying horizontally can breathe only with facility on that 
side to which the pain and sense of oppression are re- 
ferred. 

A distinction of this species from the two others 
is also afforded by the state of the cough. It is not the 
short tickling cough or tussicula which attends the tu- 
berculous consumption. The fits of coughing are as 
violent as those which occur in catarrhal phthisis; but 
they are not, as in that species, attended with copious 
expectoration. For a considerable time little or no 
expectoration occurs : Thus, the case is very different 
from what happens either in the tuberculous or catar- 
rhal phthisis. 

But, above all other circumstances, apostematous 
phthisis is characterised by those symptoms which im- 
mediately ensue on the rupture of the vomica. On 
that event a copious purulent discharge, under the form 
of expectoration, puts the nature of the case beyond 
all doubt. That the discharge then taking place con- 



m PHTHISIS PULMONALIS. ^ 05 

gists almost entirely of pus is sufficiently demonstrated 
to the patient himself both by the smell and taste; and 
if the practitioner be present when the rupture takes 
place, he also can have no doubt with regard to the 
nature of the expectorated matter. Even at after periods, 
this species is distinctly characterised by the nature of 
the expectoration. Both by its smell, its specific gra- 
vity, and its chemical relations to acids and to alkalies, 
it will be found to consist principally of pus, with very 
little mixture of mucus. 

The last species, or the tuberculous consumption, 
is the most difficult to distinguish at its commencement. 
It is what may justly be called a very insidious disease; 
and it has often made considerable progress before any 
important affection is supposed to exist. The cough 
at the commencement is hardly so considerable as to 
claim notice ; while the extenuated habit and loss of 
strength with which it is attended are often ascribed 
to other causes. But there is always some presump- 
tion that these are the incipient state of the tubercu- 
lous phthisis, when they take place between the age of 
fifteen and twenty- five, and are found to continue for 
some time, notwithstanding the use of those practices 
which are in general successful in cata; rh. There is 
still stronger ground for presuming incipient phthisis 
of the tuberculous kind, when these symptoms are at- 



BB OF THE DIAGNOSIS 

tended with quickness of pulse, and when they occur 
with those who are known to be of a scrofulous family, 
and especially if other children of the same family 
have, at the samq period of life, fallen victims to 
phthisis. 

But even where there is not this mark of hereditary 
scrofula in the family, the symptoms mentioned above 
always give strong suspicion of tuberculous phthisis, 
when they occur with those who are of that fair com- 
plexion and delicate make which is very common with 
such as are of scrofulous constitution. 

There is also reason for suspecting tuberculous phthi- 
sis where the symptoms above mentioned have begun 
without any obvious existing cause, such as injuries to 
the breast; where the pain, when it does take place, is 
not fixed to any particular spot; and when dyspnoea does 
not occur, or if occurring, is only distressing upon mo- 
tion of the body, or any considerable exertion on the 
part of the patient. 

But .above all other marks, the tuberculous phthisis 
is characterized by the peculiarity of the cough which 
takes place both at its commencement and during its 
course. The cough which attends the tuberculous 
phthisis is, as has already been said, of the short tick- 



IN PHTHISIS PULMONALIS. Ot 

ling kind, denominated a tussicula. For a long time 
it seems to proceed from some accidental irritation, and 
is attended either with no expectoration, or merely with 
the expectoration of a small quantity of mucus. Where 
a more copious expectoration does happen, it is neither 
viscid mucus nor purulent matter mixed with mucus. 
The matter expectorated is often clear and limpid, with 
a reddish tinct; and is rather a bloody sanies than 
even ill-conditioned pus. 

When bloody expectoration takes place in this spe- 
cies at an early period, it can hardly be said to be un- 
der the form of haemoptysis. The discharge of blood 
is never considerable at once, and it is very seldom pure 
blood, being in general intimately mixed with a large 
proportion of thin limpid mucus. 

From due attention to those diagnostics which have 
now been pointed out, pulmonary consumption may be 
most readily distinguished from other diseases; and 
when -it does occur, the three different species which 
have been pointed out maybe most readily distinguish^ 
ed from each other, 




5S 



CHAPTER VII. 

<3BSBRVATI0NS ON THE GENERAL PLAN OF CURE IN 
PULMONARY CONSUMPTION. 

In the different modifications of phthisis pulmonalis, 
and particularly in the three different species which 
have been now described, the general plan of cure va- 
ries considerably. It is indeed true, that there are 
some general intentions "-hieh are to be had in view 
in every instance of phthisis. Thus, it must always 
be an object with the practitioner to counteract, as far 
as he is able, the effects of purulent absorption. It is 
in every case an object of importance to obviate those 
effects which purulent absorption produces on the sys- 
tem; or, in other words, to alleviate the urgent symp- 
toms of the disease. These, however, are merely pal- 
liative indications, and a radical cure of the disease is 
to be obtained only by a removal of that source from 
which the purulent absorption arises. The means of 
effecting this removal must, in the different species, be 



GENERAL PLAN OP CURE, &C. 69 

accommodated to the nature of that particular source 
from whence the purulence is furnished. 

In the catarrhal phthisis, the source of that purulent 
matter which produces the symptoms is a mere inflam- 
ed surface, in some degree similar to what produces 
purulent matter in the case of a blister-issue. Here, 
therefore, the first object which is naturally to be aim- 
ed at in the cure is, to produce a change in that state 
of separation which takes place from the surface of the 
branches of the trachea, and of the membrane forming 
the air-vessels of the lungs. But it is also a second ob- 
ject of no less importance, to restore the natural condi- 
tion and state of action of those superficial vessels from 
which this separation is afforded. 

For obtaining the first of these ends, it is in most in- 
stances necessary to diminish that impetus with which 
the blood circulates through the system in general. 
But it is still more requisite to diminish that impetus 
with which it circulates through the vessels of the lungs 
in particular; for in catarrhal phthisis, the impetus of 
circulation in these vessels is very generally augmented, 
A diminution of this impetus may be obtained in dif- 
ferent ways. But very generally this may be effected 
more readily by those means which give a determina- 
tion ef blood to other parts at some distance from the 



BO GENERAL PLAN OF CURE 

lungs, than by an action on the vessels of the iungs 
themselves. 



The second leading indication in the cure of catar- 
rhal phthisis, the restoration of a natural condition to the 
superficial vessels ofth^ lungs, from which a separation 
of pus is afforded, may be brought about chiefly in two 
ways; first, by strengthening the tone of these vessels; 
and, secondly, by giving such a condition to the system 
in general, that tl(e restoration of proper tone to these 
vessels may be brought about by the operations of the 
system itself. Hence, with the view of fulfilling this 
indication, much more is to be derived from regimen 
than from medicines, and particularly from gentle ex- 
ercise, pure air, and mild nutritious diet. 

In the apostematous phthisis, the purulent matter 
which gives rise to the wasting of the habit, loss of 
strength, and hectic fever, is separated at a particular 
part of the lungs, and is often, even when locally accu- 
mulated at that part in considerable quantity, so inclos- 
ed that it cannot be discharged; for the apostema is 
often formed by a thick cyst or bag containing the pu- 
rulent matter. Thus, the purulent matter, although 
lodged in the substance of the lungs, even to the extent 
of many ounces, has no communication with any branch 
of the trachea. In other cases, however, even before 



■ 



IN PULMONARY CONSUMPTION. 61 

the vomica can properly be said to be ruptured, some 
communication with the air vesicles, and passages for 
air, takes place. But whether there be any opening 
into these, giving an opportunity for purulent expecto- 
ration or not, it is still from this source, the apostema, 
that the absorption of matter giving rise to consumption 
is afforded. 

In this species of phthisis, then, it must be evident, 
that a first and principal object is to discharge that 
purulent matter which is collected in the apostema. 
For accomplishing this, when the cyst remains entire, 
the first requisite is, that it should be ruptured; 
and for this purpose, measures may sometimes be ad- 
vantageously employed by the physician; such, for ex- 
ample, as concussion of the system by the action of 
vomiting, of coughing, or the like. But very general- 
ly, the rupture of the apostema is trusted to the opera- 
tions of nature; and in most instances, in no long time, 
particularly if the vomica be large, a spontaneous rup- 
ture will occur. 

In every case, after an opportunity for discharge is 
afforded, whether by an intentional or spontaneous rup- 
ture of the apostema, that discharge is to be promoted; 
and this may be done by encouraging frequent and free 
expectoration. Such expectoration, it is almost unne- 



GENERAL PLAN OF CURE 

pessary to observe, is chiefly effected by coughing. And 
in the greater part of instances, sufficiently frequent 
and strong coughing is induced from that irritation 
which is given to the lungs and trachea by the puru- 
lent matter itself; but in some instances, for promoting 
free expectoration, other measures may be employed 
with advantage, such as the steam of water, of vine- 
gar, of sulphuric ether, or similar vapours. 

After a discharge of that purulent matter which 
had been collected in the abscess has been obtained, it 
becomes a second object in apostematous consumption 
to prevent the farther separation of purulent matter 
from the ulcer which is thus formed. This, however, 
can only be accomplished in a manner similar to what 
happens when ulcers are formed in other parts. On 
the bursting or opening of an abscess, a diminution and 
tinal termination of the discharge are only to be brought 
about by the gradual healiug of the ulcer. This healing 
of ulcers, however, in the lungs, as well as other parts 
of the body, may justly be considered as a process of 
nature, and is only to be accomplished by the operations 
of the system itself. 

But there can be no doubt, that, on some occasions, 
the efforts of nature, in conducting the healing process, 
may be promoted and forwarded. This healing process 



IN PULMONARY CONSUMPTION. bo 

requires that state of action of the vessels, which, in 
contradistinction to the suppurative^ has been termed 
the adhesive inflammation. It becomes, therefore,an ob- 
ject of importance to induce this state of inflammation 
as far as it can with safety be done. And with this 
view, by the judicious use, sometimes of tonics, 
sometimes of stimulants, sometimes of astringent 
medicines, much good maybe obtained. 

The third and last species of consumption to be 
spoken of, the tuberculous, depends on what are term- 
ed tubercles formed in the lungs, and which are pro- 
bably diseased and indurated glands attached to the 
lymphatic system. These, as well as scrofulous tumors 
in other parts of the body, depending also on the in- 
duration and enlargement of lymphatic glands, may 
often long remain in an indurated state. But such 
tumors in the lungs, as well as similar tumors else- 
where, may be considered as having constantly a ten- 
dency and even a progress to a state of suppuration. 
And suppuration a* these tubercles may take place, not 
merely in the indurated body itself, which sometimes 
becomes as it were an inorganic substance, but in 
those parts by which it is immediately surrounded; 
the tubercle merely acting in exciting the suppurative 
inflammation, in the same manner as a lead-shot, or anv 



64 GENERAL PLAN OF CURE 

similar foreign substance, introduced into the lungs, 
would do. 



It is in but very few cases of tuberculous phthisis 
that a single or solitary tubercle only exists in the 
lungs. In the greater number of instances, as is demon- 
strated by numerous dissections, many tubercles exist 
in the lungs at the same time. And when some have 
already terminated in a state of suppuration, or have 
induced the separation of ill-conditioned purulent mat- 
ter from the vessels immediately in contact with them, 
others remain only in the progress towards a state erf 
suppuration. And from this circumstance many pheno- 
mena of the disease may be explained; particularly 
the recurrence of phthisical symptoms in a patient for 
several years together every spring, and their cessation 
during the summer. This may be considered as hap- 
pening in a manner precisely similar to scrofulous sup- 
purations, scrofulous ophthalmia, or the like, returning 
frequently during a series of years, at almost stated times. 

Wherever tubercles formed in the lungs can be re- 
moved without terminating in suppuration, or inducing 
suppuration in contiguous parts, this removal is un- 
questionably a matter of the utmost consequence. In 
tuberculous phthisis, it is an object of great importance, 
wherever it can be accomplished, to bring about a 



IN PULMONARY CONSUMPTION. 65 

resolution or removal of the tubercles, while they re- 
main in their indurated state. 

But this resolution or removal may be accomplish- 
ed with some of the tubercles, although not with all 
of them; and where many exist, it may reasonably 
be expected that some of thenv will terminate in sup- 
puration. Where such a termination takes place, 
it is but very seldom that the ulcer, thus formed, 
yields mild purulent matter. Like scrofulous ul- 
cers in other parts of the body, those ulcers in the 
lungs which are the consequence of tubercles, often 
give out merely an ichorous sanies. In this species 
of phthisis, therefore, a second great object in the 
cure is, to alter the state of action of the vessels, 
either in the tubercle itself, or in the surrounding 
parts, so as to produce the separation of proper puru- 
lent matter. 

With the separation of proper purulent matter, 
the adhesive inflammation, by which alone an ulcer 
can be healed, is intimately connected; and it is alone 
by the healing of the ulcer that the disease can be 
cured. If, however, this object can be accomplished 
by the aid of proper remedies, or even if the opera- 
tions of nature in accomplishing it can be aided, a re- 
covery may take place even from this most alarming 

and dangerous species of consumption, the tuberculous, 
f 2 



m 



CHAPTER VIIL 

OBSERVATIONS ON PARTICULAR PRACTICES EMPLOYED 
IN PHTHISIS PULMONALIS, AND WHICH HAVE BEEN 
RECOMMENDED BY EMINENT WRITERS. 

From the view which has been given of the general 
principles on which the cure of pulmonary consump- 
tion is to be conducted, it must evidently appear, that, 
for answering the indications which have been pointed 
out, many different remedies may be employed; and 
there is perhaps no affection in which a greater variety 
of practices have been recommended. 

While some of these practices are applicable to one 
species and one condition of the disease only, others 
are in some degree applicable perhaps to all the three 
species which have been described, and may even be 
advantageously employed to fulfil different intentions in 
each. But although it has of late been alleged by an 
eminent writer, that the digitalis purpurea is as certain 
a remedy for phthisis, as the cinchona is for intermit- 



MODES OF CURE, &C. 67 

tent fever, yet every candid practitioner wi 1 ! readily 
allow, that hitherto no panacea, no effectual remedy for 
pulmonary consumption, is discovered. 

In particular instances, however, certain remedies 
may not only tend to alleviate the distress of the patient, 
but may at least assist in the accomplishment of a com- 
plete recovery. This will more fully appear from a 
few observations on the principal practices which have 
in this disease been recommended by the most eminent 
practitioners. 

This subject might easily be extended to a gre^p* 
length, when it is considered how many different reme- 
dies have been recommended in phthisis, and how 
much has been said with regard to each. From what 
I have seen in actual practice, I might say much, both 
in confirmation and in refutation of the sentiments of 
others respecting particular remedies. But my object 
is to deliver not the detail, but the result of my own 
observations; and I shall therefore confine myself to 
a few remarks on what I consider as the most important 
modes of cure, either from their beneficial or preju- 
dicial effects. 

At the head of the practices which have been re- 
commended in pulmonary consumption, blood-letting 



O'S 310DES OP CURE 

may justly be -mentioned. There are several indica- 
tions in phthisis, which it is well fitted to fulfil, especi- 
ally as diminishing the impetus of blood through the 
system in general, and through the lungs in particular. 
In this way large and repeated blood-lettings may effec- 
tually prevent haemoptysis, or inflammation from any 
cause, from terminating in a state of suppuration. Re- 
peated small bleedings in phthisis have also been 
strongly recommended, for counteracting successive 
inflammations resulting from tubercles. 

The use of repeated blood-lettings in phthisis seems 
«fcst to have been introduced by that singular practitio- 
ner Dr Dover, to whom, it must be acknowledged, that 
medicine is indebted for several important practices; 
particularly for the introduction of his sweating pow- ■ 
der, long known in the shops under the name of Dover's 
Powder, and still much employed under the appella- 
tion of the pulvis ipecacuanha composilus. Dr Dover 
considered phthisis as entirely an inflammatory disease. 
And he directed blood-letting to a small extent at first 
every ay, for twelve or fourteen days successively; 
and afterwards every second or third day for a consider- 
able length of time. In this way, even by small blood- 
lettings, very considerable quantities were abstracted; 
and there are cases on recoid. in which, before the 
disease proved fatal, blood-letting ^ad been performed 



IN PHTHISIS PULMONALIS. 69 

upwards of fifty times. There can, however, be no 
doubt that this was a great abuse of a very useful reme- 
dy. The treatment was found to be by no means a 
successful one; and although these blood-lettings might 
afford temporary relief, yet the probability is, that 
they shortened the life of the patient. 

On the grounds, indeed, which have already been 
stated, blood-letting may in some instances prevent the 
occurrence of the disease, and in others overcome it 
in its incipient state; but it is to be remarked, that no 
practice tends more to reduce the strength of the body 
than blood-letting. Loss of strength, however, occurs 
at a very early period of phthisis, and is one of the 
first alarming symptoms. The pulse in this disease is 
often quick, when it is neither full nor hard; and the 
quickness depends much more on increased irritability, 
than on increased tone of the vascular system. Hence, 
it is often observed,that blood-letting, in place of dimin- 
ishing, increases the quickness of the pulse in phthisi- 
cal patients; and in every case it occasions an addition- 
al loss of strength. There can be no doubt, there- 
fore, that it must often be prejudicial. That it has 
been so, I am fully convinced from what I have fre- 
quently seen in practice; and I have no doubt in assert- 
ing, that in hundreds of instances, starvation and blood- 
letting have hastened the death of phthisical patients. 



<U 3I0DES OF CURE 

With regard to its use in this disease, it may be justly 
observed, hi the words of an elegant writer, Nocet per 
se,prodest casu. 

As blood-letting has often been employed in phthisis, 
so recourse has frequently been had to blisters. Epis- 
pastics have in this disease been used in different forms, 
particularly under the form of proper blisters, and of 
blister-issues, or setons. It may also be observed, that 
in some instances they may be employed with advan- 
tage in all the three different species of phthisis. In 
every species of the disease, blisters are often a means 
of relieving the cough: for even when they have no 
tendency to remove the stimulating cause producing 
cough, as when it arises from a tubercle, yet they di- 
minish the effect of the stimulus. In most instances, 
also, they diminish increased sensibility in the neigh- 
bourhood of those parts to which they are applied. This 
is particularly the consequence of their application to 
the neighbourhood of inflamed parts: for by exciting 
a new morbid action, that which previously took place 
at the inflamed part is sometimes suspended, often di- 
minished. Thus, they are useful rather from the im- 
pression which they make on certain subcutaneous 
nerves, and the consequent inflammation which they in- 
duce, than from their evacuant power. 



IN PHTHISIS PULMONALI: 



11 



But even as evacuants they are of some service in 
phthisis, by producing a discharge from the general 
system, and perhaps still more by changing the dis- 
tribution of the fluids, and the balance of circulation. 
While, however, with the intention of evacuating, 
the greatest effect is to be expected from proper blis- 
ters; with the view of changing determination, more 
benefit may be derived from blister-issues, or from 
setons. 

Blisters, and still more blister-issues, are particular- 
ly useful in the catarrhal phthisis: for in that modifi- 
cation of the disease, derivation from the lungs is of 
the utmost consequence. "By this means, a change 
may often be affected in that state of suppuration which 
takes place from the internal membrane of the lungs, 
and the purulent discharge may thus be converted into 
the natural mucus. On the same principles they are 
useful in catarrh. Hence, they may be considered as 
particularly adapted to that period of the disease, when 
a catarrhal has a disposition to degenerate into a phthi- 
sical affection: and for my own part, I am acquainted 
with no remedy from which I have seen so much 
benefit, in the incipient state of catarrhal phthisis, as 
from blister-issues on the breast. 

In the apbstematous phthisis, blisters and blister- 



"i% -UOUES OF CURL 

issues are also of considerable service, particularly 
while the vomica remains entire. For there is reason 
to presume, that this evacuation both tends to remove 
matter from the vomica, by increasing absorption, 
and that it also affords an outlet for the matter thus 
absorbed from the circulating mass. But after a rup- 
ture of the apostema has taken place, and after an 
opportunity is ^hus afforded for a free discharge of 
the purulent m jitter by expectoration, less benefit is 
to be expected from issues; and as every evacuation 
has a tendency to increase debility, issues are in some 
degree exceptionable. 

Perhaps on the same ground they are still nioic 
exceptionable in the tuberculous phthisis. In that 
modification of the disease, I have never in my own 
practice observed any decided advantage resulting 
from the employment of them; and in some instances, 
besides evacuating, they are productive of great incon- 
venience, as exciting irritation and pain. Circum- 
stances, however, not unfrequently occur, indicating 
their use even in the tuberculous phthisis; particularly 
if that species be attended with considerable expecto- 
ration of mucus, which is at least sometimes the 
case. Even in tuberculous phthisis, therefore, the 
use of issues is by no means to be entirely forbid. 
But, upon the whole-, they are less beneficial in that 



IN PHTHISIS PULMONALIS. 73 

species of consumption than in the other two, par- 
ticularly than the catarrhal, in which they are often 
highly useful. 

Among other remedies in phthisis pulmonalis, some 
have very strongly recommended the use of emetics. 
These, in certain circumstances, are applicable also 
to all the three species of pulmonary consumption; 
and perhaps they may be useful on a greater variety of 
grounds than either of the practices already mentioned. 
In the catarrhal phthisis, the induction of full vomiting 
is often highly useful as an expectorant: for in that dis- 
ease, as well as in chronic catarrh, both the cough and 
dyspnoea arise from viscid matter accumulated in the 
branches of the aspera arteria; and, next to coughing, 
nothing so im mediately' produces a discharge of that 
matter as the action of vomiting. But besides operat- 
ing as an expectorant, the action of an emetic is also 
useful in catarrhal phthisis, from the general agitation 
which it occasions. By this there can be no doubt 
that a very great temporary change is induced in the 
mode of circulation. By the action of vomiting, the 
blood is propelled to the extreme vessels in every part 
of the body, particularly to the extreme vessels on the 
surface. Thus, there is produced a derivation from 
the lungs, and a consequent change in the state of 
separation at that part of the system; and superficial 



74 MODES OF CURE 

vessels which before secreted a purulent matter, may 
thus come to yield a more natural secretion. In this 
way, they may tend to produce a radical cure. But as 
far as I can judge from my own observation, they are 
chiefly useful in catarrhal phthisis, as obviating symp- 
toms, particularly cough and dyspnoea, by promoting 
expectoration. 

If, with the intention of promoting expectoration, 
emetics are often productive of good effects in the 
catarrhal, on the same ground they are still more use- 
ful in the apostematous phthisis. Where, indeed, we 
have reason to conclude that there is a large vomica 
in the lungs, but that it still remains entire, and while 
our wish is that it should not be burst, emetics must 
carefully be avoided. But where, ^thout a rupture 
of the vomica a cure cannot be expected, we possess 
no practice by which a rupture can be more readily ob- 
tained, than by the action of vomiting; and after a 
rupture of the apostema has taken place, whether spon- 
taneously or by artificial means, emetics may be of 
great service, as promoting the evacuation. Thus, in 
apostematous phthisis, they may be advantageously 
employed with different intentions. 

The intentions now pointed out are seldom to be an- 
swered in the tuberculous consumption. For there. 



IN PHTHISIS PULMONALIS. 



iie promoting expectoration will rarely alleviate either 
cough or dyspnoea. But in tuberculous phthisis, eme- 
tics have been perhaps more extolled than in either of 
the other species; and if they have really the effect 
which some eminent practitioners have alleged, much 
may be expected from them. It has been contended, that 
by emetics a resolution of tubercles in the lungs may be 
brought about; and in the most dangerous species of the 
disease even a radical cure will be effected, if the tuber- 
cles can beremoved. These tubercles, as was formerly ob- 
served, are probably tumors of the scrofulous kind; and 
of late, amongother proposals for discussingscrofulous and 
other glandular tumors, emetics have been recommended. 
They have particularly been advised for removal of a 
swelled testicle. When, indeed, the testis is in a state of 
acute inflammation, emetics are not to be recommended. 
But when swelling and hardness remain after the ac- 
tive inflammation is gone, they have been extolled by 
some practitioners as more useful in removing that 
swelling than any other remedy. On this ground, it 
has been inferred, that they may be advantageously 
employed against other glandular tumors, even those 
of the scrofulous kind. . Accordingly, the frequent use 
of emetics, repeated twice, or even thrice, in the course 
of a week, for some length of time, has been strongly 
advi< n d; and cases have been published, in which this 
practice is said to have effected a radical cure in tuber- 



76 MODES OF CURE 

culous phthisis. I must acknowledge, that I cannot 
say very much in favour of this practice from my own 
experience. And I have never yet met with any in- 
stance of tuberculous phthisis, in which I had reason 
to believe that emetics produced a radical cure. I, 
however, by no means consider them as being so dan- 
gerous a remedy as the repeated small blood-lettings 
I have never seen any bad effect from the prudent use 
of them: And in most instances of tuberculous phthisis. 
I have found them, in the early stages of the disease, 
productive of some temporary relief, probably as giving 
temporary determination to the surface of the body. 

Those practitioners who have recommended emetics, 
have differed somewhat with regard to the particular 
emetic which ought to be employed. Some have advis- 
ed the use of ipecacuanha. And certainly where full 
vomiting is required to a moderate degree, there is no 
article on which greater dependence can be put. But 
Dr Marryatt and others give the preference to what 
he has termed the dry vomit, that is, an emetic opera- 
ting without the introduction of any great quantity of 
fluid. The dry vomit recommended by him is com- 
posed of sulphat of copper and tartrate of antimony; 
and it has the effect of exciting vomiting immediately 
upon being swallowed. My excellent friend, the late 
Dr Simmons, in his Essay on Consumption, mentions. 



IN PHTHISIS PULMONALIS. T7 

that in two cases he had experienced benefit from this 
emetic, after vomits pf ipecacuanha had been given 
ineffectually. Where very frequent repetition is to be 
tried, this dry vomit is perhaps to be preferred. But I 
must confess I have no expectation, that, by the use of 
any emetic, a removal of tubercles from the lungs will 
be often obtained. And where the chief intention in 
the use of emetics is to promote expectoration, the ipe- 
cacuanha is perhaps the best that can be em- 
ployed. 

A considerable variety of medicines of the refri- 
nerant kinds, have been strongly recommended by dif- 
ferent practitioners for combating phthisis in its inci- 
pient state. Refrigerants, which, while they tend to 
produce a sense of coolness, at the same time diminish 
the impetus of circulation, may seem well suited to a 
disease which by some has been supposed to be always 
of an inflammatory nature; and although they do not 
immediately remove a plethoric state, yet they perhaps 
tend to diminish the inflammatory diathesis even more 
effectually than the repeated blood-lettings. Hence, it 
is not wonderful that recourse should have been had to 
them, and that in certain circumstances they should even 
have been productive of material advantage. Accord- 
ingly, at different periods, different articles of the re- 
frigerant kind have been highly fashionable. Acids 



78 MODES OF CURE 

and neutral sails, particularly nitre, have by some prac 
titioners been strongly recommended in phthisis, 

Among the former, recent vegetable acids, such as 
that obtained from lemons, oranges, or other acescent 
fruits, were at one time highly extolled. Lemons, in 
particular, taken to a very great extent, were, on the 
authority of a late eminent London physician, repre- 
sented as an almost infallible remedy in phthisis. I 
have been told, his own observation on this subject was, 
that, although the lemon juice often did not succeed 
with others, yet with him it seldom failed. There is, 
however, too much reason to believe, that, even under 
the very best management, lemon juice will very rare- 
ly, if ever succeed in curing any species of phthisis, 
where the disease is certainly characterized; and there 
is a high probability, that many of those cases in which 
it was said to produce a cure, though supposed to be 
phthisis, were merely catarrh. Judging from what I 
have myself observed in practice, I have no doubt in 
asserting, that the powers of lemon juice, and of other 
articles abounding with vegetable acid, in combating 
ph hisis, have been by some practitioners greatly over- 
rated; nay, that the indiscriminate use of vegetable 
acid, as well as of repeated blood-letting, in pulmo- 
nary consumption, has been attended with very se- 
rious evils. 



tN PHTHISIS PULMONALIS. 79 

I must, however, also remark, that from recent ve- 
getable acids, and particularly from the acid of lemons 
or oranges, I have often experienced good effects in 
particular cases of phthisis. These acids can be taken 
without inconvenience to a much greater extent than 
either the acetous or the mineral acids. And wherever 
refrigerants are indicated in phthisis, the recent vege- 
table acids are perhaps the best. There are certain 
circumstances in which they may be proper in all the 
three species of consumption. But they will no more 
cure tuberculous phthisis than they will cure scrofula 3 
when affecting the submaxillary or other subcutaneous 
lymphatic glands; and there is as little reason to hope, 
that a large abscess in the lungs can be combated by 
the use of them. 

They may perhaps sometimes prevent the inflamma- 
tion which occurs in tubercles, from passing into a 
state of suppuration: or they may be useful in combating 
inflammation from injuries to the breast, where that 
inflammation would otherwise terminate in an apos- 
tema. They may also be useful where frequent returns 
of haemoptysis threaten a termination in suppuration, 
But after an abscess has occurred they are of little 
service. And as far as my observation goes, they are 
chiefly beneficial in those cases where there is reason 
to dread that catarrh will degenerate into phthisis, 



00 MODES OF CURE 

• Besides different acids, various other articles have 
been frequently used in phthisis, the good effects of 
which are probably to be ascribed to their power as re- 
frigerants. Recourse has particularly been had to the 
nitrate of potass, and to the supertartrate of potass, 
both of which, but particularly the former, have very 
great influence in exciting a sense of coldness from 
their action on the stomach, and are certainly justly 
entitled to the appellation of refrigerants. The for- 
mer, has been much employed in cases of haemop- 
tysis, and the latter is often useful, both as a refri- 
gerant and gentle laxative, in those cases where, with 
symptoms threatening phthisis, there takes place a 
bound state of the belly. But they seem to me to be 
inferior in efficacy to the recent vegetable acids; and 
unless where these disagree with the stomach, neither 
nitre nor cream of tartar will probably be much em- 
ployed merely as refrigerants. 

When these neutrals are had recourse to with con- 
sumptive patients, they are used rather with the view 
of correcting some other article, than with any expec- 
tation of deriving benefit from the neutrals themselves. 
Thus, it has been strongly recommended to conjciu 
nitre with the gum myrrh, an article afterwards to be 
spoken of. And it is not improbable, that both this 
and the cream of tartar might be advantageously added 



IN PHTHISIS PULMONALIS. 31 

to some other of the heating balsams, as they have been 
called; and that by this combination, while good ef- 
fects are obtained from these balsams, certain bad ef- 
fects which some have attributed to them might be 
counteracted. Thus, in different conditions of the dis- 
ease various refrigerants may be employed with ad- 
vantage. 

Of all the remedies which have of late been fashion- 
able in phthisis, none, perhaps, has been so highly ex- 
tolled as the digitalis purpurea. One practitioner, as 
has already been remarked, represents it as being as 
efficacious in the cure of phthisis, as the Peruvian bark 
is in cases of intermittent fever. But extensive expe- 
rience has already clearly demonstrated to many dif- 
ferent practitioners that this is a mere chimera. The 
foxglove has unquestionably a wonderful influence on 
the state of the pulse. Under proper management, it 
produces a slowness of the pulse, not perhaps to be ob- 
tained from any other medicine yet discovered. In 
phthisis, however, the pulse is often quickened to a re- 
markable degree. And it has been the opinion of some, 
that, by reducing it to the natural standard, from the 
emplo} T ment of digitalis, consumption may be overcome. 
But it is almost unnecessary to observe, that the quick- 
ness of pulse in phthisis is merely symptomatic, and 
that the reduction of it even below the natural stand- 



82 MODES OF CURE 

ard, can have no effect either in removing a tubercle, 
or in healing an ulcer in the lungs. Hence, on this 
ground, it is in vain to expect a radical cure from its 
use. That in certain cases, however, it may be em- 
ployed with advantage, I am very far from denying. 



The foxglove, besides that in general it diminishes 
the celerity of the pulse, in most instances also ope- 
rates as a very powerful diuretic. It is. however, well 
known, that a free discharge of urine has often great 
influence in relieving the breast. This is clearly de- 
monstrated by the benefit obtained from different diu- 
retics in chronic catarrh. In this way digitalis may be 
highly useful in catarrhal phthisis; and a diminution 
of the celerity of the pulse may certainly somewhat 
alleviate the hectic fever. But I am sorry to say, that, 
for my own part, I have not witnessed any great bene- 
fit from digitalis in any case of phthisis; and I have 
seldom been able, by means of this article, so far to 
diminish the celerity of pulse in phthisis, as to bring it 
even to the natural standard. It would seem, that in 
this disease, such is the influence of the causes quick- 
ening circulation, that even the power of the digitalis 
is not able to counteract them. 

While cow's-milk, in various forms, as an article of 
diet, has been very generally recommended to phthisi- 



IN PHTHISIS PULMONALE. 83 

tal patients, some particular kinds of milk have been 
viewed even as effectual remedies in that disease. With 
this intention, women's milk, mare's milk, but particu* 
larly ass's milk, have been by some highly extolled. 
Some kinds of milk may certainly agree better with 
particular stomachs than others. But there can be no 
doubt, that none of them operate upon any other prin- 
ciple than as a mild and nutritious article of aliment; 
and therefore, that no benefit is to be expected from a 
small quantity. From ass-milk, which has often been 
directed to the extent only of a gill in a day, no benefit 
is to be expected, unless it be taken to the quantity of 
at least half a pint twice a-day. When thus used, I 
have often found it beneficial to patients highly debili- 
tated; and I am much deceived, if it has not in some in- 
stances contributed to the removal of tuberculous con- 
sumption in its incipient state; only, however, from 
aiding the operations of nature, by strengthening the 
patient. But, such is its influence in this way, that, 
in the incipient state of every instance of tuberculous 
phthisis, it should be recommended. Where the sto- 
mach of the patient can easily digest it, the same ad- 
vantages may be derived from cow-milk, and that, too ? 
in its richest state, under the form of what have been 
called the afterings, that is, the last portion of milk 
drawn from the udder of the cow at any one period of 
milking. These offerings^ &s has been found by accu- 



84 MODES OF CURE 

rate observation, certainly contains a much greater pro- 
portion of butyraceous matter than is to be found in the 
first drawn milk, and this last drawn portion of the 
milk is unquestionably the most nutritious. But often 
cow-milk, even of the ordinary richness, cannot be di- 
gested. In that case, however, it may still be success- 
fully employed in a diluted state; and diluted cow- 
milk, with the addition of a small portion of sugar, will 
make a very good substitute for ass-milk, where that 
article cannot easily be obtained. 

The wkey of goat-milk, is another article in which 
many practitioners put great confidence. From goat- 
whey, as well as from ass-milk, I think I have often 
seen very great advantage, particularly in the incipient 
state of tuberculous phthisis. I have known more than 
one instance where a patient of a scrofulous family 
had for several successive springs alarming phthisical 
syiiiptoms, which were entirely removed in the course 
of the summer, by leaving Edinburgh, and drinking 
goat-whey in the Highlands. This could not be at- 
tributed to any nourishment obtained from the most 
watery part of the milk, deprived both of the oleagi- 
nous and coagulable matter. But it has been supposed 
by some, that goat- whey may acquire particular vir- 
tues from an impregnation given to the milk by those 
herbs on which the s:oat feeds in her native hills. For 



IN PHTHISIS PULM0NAL1S. 85 

this, however, there is just as little foundation as for 
the supposed medical virtues of ass-milk. I have, for 
my own part, no doubt in attributing the whole benefit 
of goat-whey, to pure air, gentle exercise, and the 
change of temperature of the season during which re- 
course is usually had to it. In proof of this, I have of- 
ten observed the same benefit by removal from a town 
residence to comfortable country quarters, where no 
goat-whey was to be had. A change of situation to 
pure air and a temperate atmosphere, will often be 
found of material advantage. And it is with these in- 
tentions alone that I ever think of recommending 
goat-whey quarters. But from removal to these during 
the summer season, I have often seen great benefit in 
the incipient state of tuberculous phthisis. 

For patients in the incipient state of a pulmonary 
consumption, sea voyages have often been highly ex- 
tolled. These have been recommended in every spe- 
cies of the disease; and on different grounds they have 
been imagined to be productive of advantage. By 
some, they have even been supposed useful as exciting 
sea-sickness. But more generally the benefit observed 
from them has been attributed to two other circum- 
stances: to the pure air which the patient must neces- 
sarily breathe when at sea; and to the constant state 
of motion to which the body is subjected, when on ship- 



SQ SI ODES OF CURE 

board. Some have even thought, that particular bene- 
fit may be derived from breathing sea-air, which is 
well known to be often impregnated with saline matter. 
That on all these grounds some benefit may be deriv- 
ed from it, I would be far from denying; and I have 
known some instances of patients who were suspected 
to labour under tuberculous phthisis, for whom, on the 
very first alarm of the disease, a long sea-voyage has 
been recommended, and who have returned free from 
every complaint. But in the catarrhal and apostema- 
tous phthisis nothing is to be expected, either from 
the air or exercise which a sea-voyage affords, nor 
from the inspiration of a saline atmosphere. And 
even in the tuberculous phthisis, after the disease is so 
far advanced as to be distinctly marked, I have never, 
for my own part, known any benefit from a sea-voyage; 
while, on the other hand, phthisical patients in a very 
debilited state, at sea in stormy weather, are subjected 
to so many and so great inconveniencies, that I have 
often known those who have attended such patients 
deeply regret that the practice had been tried. 

Unless, therefore, where sea-voyages are necessary 
for transporting a patient from Britain to another cli- 
mate, they are, in my opinion, very rarely adviseable. 
But few remedies have been more generally recom- 
mended by eminent practitioners for combating phthi- 



IN PHTHISIS PULMONAUS. 81 

sis, than a change from Britain to a more steady and a 
more temperate climate. A voyage to Lisbon, to Mont- 
pellier, to Messina, and other places in the south of Eu- 
rope, with a residence there for some length of time, 
have been strongly recommended. While these situations 
from the wars lately prevailing in Europe, were subject- 
ed to the danger of invading armies, Madeira,the Canary 
Islands, the Azores, and Bermuda, have been advised, 
with a similar intention. And there can be no doubt, 
that, in these climates, exercise in the open air may be 
employed much more regularly, and with much less 
risk, than in the variable and cold climate of Britain. 
Yet a change to any climate has very little, or rather 
no influence, as tending to a radical cure of the disease; 
and the greater part of those patients from Britain who 
have had recourse to this practice, after phthisis has 
been distinctly marked, have only gone to breathe their 
last in a foreign climate^ 

The different modes of cure which have now been 
mentioned, are perhaps the principal practices which 
have been recommended by the most eminent practiti- 
oners in the earlier periods of pulmonary consumption 
And where phthisis can be combated by medical aid, 
it is chiefly to be done in the incipient state. But even 
from the advanced stages of the disease, natural reco- 
veries have sometimes taken place. Hence, then. 



88 MODES OF CURE 

though artificial means of cure, or remedies, strictly so 
called, are frequently unsuccessful, yet there are many 
cases where a practitioner, who has had no opportunity 
of seeing the patient till the disease has arrived at 
what may be called a confirmed state, may recom- 
mend them with some prospect of benefit. 

Among the articles employed in advanced periods 
of phthisis, there are perhaps few with regard to which 
greater controversies have subsisted than respecting 
the cinchona, or Peruvian bark, as it has been common- 
ly called. 

There are severalcircumstancesiuphthisis, from which 
cinchona would seem naturally to be indicated. But. 
on the other hand, there are circumstances from which 
it might be concluded to be adverse to the nature of the 
disease. This controversy cannot perhaps be yet de- 
cided from any facts that have been published respect- 
ing the employment of cinchona in phthisis. For if 
it be said that there are cases recorded in which it has 
been used with advantage, it may on the contrary be 
observed, that there are others in which it has manifest- 
ly been productive of bad effects. 

Cinchona might, a priori, be concluded to be useful 
in phthisis, both as a means of healing ulceration o( the 



IN PHTHISIS PULMONALIS. 89 

lungs, and as counteracting those effects which arise 
from the absorption of purulent matter. It is well 
known, that in cases where ulceration takes place on 
different parts of the surface of the body, the discharge 
of purulent matter is often altered and meliorated un- 
der the use of Peruvian bark. It has also been ascer- 
tained, by many accurate experiments, that few arti- 
cles of the materia medica possess a greater antiseptic 
power; and in many cases, cinchona has been found 
efficacious in checking hectic fever arising from ulcers 
in different parts of the body. On these grounds, then, 
there is at least analogy for supposing that it may be 
useful in phthisis. 

On the other hand, however, it is well known that 
the common Peruvian bark, the cinchona laneifolia, has 
very generally a tendency to check expectoration; and ? 
in many instances, the principal chanee of cure in 
phthisis depends on free expectoration. But besides 
this, cinchona has also a tendency to produce in the 
human body an increased action of the vascular system, 
and a disposition to inflammation; hence it may tend 
to support rather the suppurative inflammation, than 
the adhesive process. On these grounds, then, there 
is reason to fear, that the good effects which may be 
expected from it, may be even more than counterba- 
lanced; and certainly its use in phthisis has, from ex- 



DO MODES OF CURL 

perience, been much condemned by many eminent 
practitioners. 

Those, however, who indiscriminately condemn the 
use of cinchona in every instance of phthisis, have 
gone too far. It must indeed be allowed, that it has 
by no means the same powerful effect in checking hec- 
tic fever, as in stopping the paroxysms of intermittents, to 
which the hectic paroxysms have in many respects a re- 
semblance. In certain cases of phthisis, it may do mis- 
chief. But this may in a great measure be avoided by pru- 
dent management; and I have directed it in several in- 
stances, in which, if I have not been much deceived, it 
has been productive of material benefit. 

In the tuberculous phthisis, it can hardly indeed be 
expected, that cinchona will cure those ill-conditioned 
ulcers which take place in the lungs: For it is well 
known, that scrofulous sores on other parts of the body 
are not to be healed by the use of it. Aud although 
iu tuberculous phthisis, little is to be dreaded from it^ 
influence as checking expectoration, yet more is to be 
apprehended from it than in any other species of phthi- 
sis; for there is reason to fear, that it may encourage 
the inflammation of different tubercles in succession, 
md thus lead to more numerous suppurations. 

Tn the catarrhal phthisis, from its influence in check- 



IN PHTHISIS PULMONALIS. 9! 

ing expectoration, it may be thought to be se3dom ad- 
missible. For in that species of the disease, free ex- 
pectoration is particularly necessary. And if the cin- 
chona be impudently thrown in, to a great extent, it is 
not wonderful that dyspnoea should be induced, or, if it 
existed before, should be augmented. But whether an 
increase of dyspnoea will be the effect of its use or not, 
can be determined only by a prudent trial. When 
dyspnoea is not induced or aggravated by its employ- 
ment, the best effects are often observed to arise from 
it. It is sometimes beneficial, not merely as restrain- 
ing colliquative sweats and other excessive discharges, 
which very much weaken the patient; but it has even 
some tendency to a radical cure of the disease. In this 
way, it has in some cases very considerable influence, 
both from altering that state of secretion which in 
catarrhal phthisis takes place from the internal surface 
of the lungs, and alsofrom restoring to the secreting 
vessels at the lungs that condition and that, tone on 
which the natural secretion in a state of health de- 
pends. 

If cinchona be sometimes admissible and useful in 
the catarrhal phthisis, it is no less so in the aposterna- 
tous. It is never, perhaps, adviseable soon after the 
rupture of a large vomica has taken place; for at that 
period, the only chance of recovery depends on free 



WZ MODES OF CURL 

expectoration. But when the discharge from the lungs, 
aTtei --pious evacuation of well digested pus has 

takes* generates into a more ichorous fluid, 

cinchona may be of great service. Under its use, 
the appearance of the matter expectorated is, in some 
cases at least, soon much changed for the better. And 
I have had reason to think, that, from its influence, 
the adhesive inflammation has been induced, am: an 
ulcer in the lungs has thus been healed, where that 
event would not otherwise have taken place. To this 
species of consumption, then, it is, perhaps, better 
fitted than to any other; and from what I have seen in 
practice, I have do doubt, that in those cases in which 
it is not productive of immediate inconvenience from 
restraining expectoration, it will be productive of 
beneficial consequences. 

In cases of phthisis, cinchona may be exhibited in 
various forms. The choice will in some degree be 
regulated by the state of the patient's stomach. But 
under whatever form it be given, it is very generally 
proper that its use should be begun in small doses; for 
by this means, the practitioner will best be able to judge 
with certainty whether its good or bad effects mil 
preponderate. In phthisis, those objects which the 
practitioner would wish to accomplish by means of the 
cinchona, are in general to be obtained, not from it? 



IN PHTHISIS PULMONALIS. Do 

action on the stomach, hut from its introduction into 
the system; and therefore they may be more readily 
obtained when its active principles are previously ex- 
tracted by a proper menstruum, than when they must 
be extracted from the woody part in the stomach it- 
self. One of the best and safest forms under which 
the cinchona can be employed in phthisis, is, perhaps, 
the simple watery infusion; and under this form, 
where cinchona is to be tried, its use ought always to 
be begun. If the watery infusion be found to be at- 
tended with advantage, the practitioner may with 
greater freedom venture to employ it in a more active 
form; and recourse may be had with advantage either 
to the extract or to the powder of the bark; yet, upon 
the whole, it will, perhaps, in a majority of cases, be 
exhibited with greater safety and most advantage when 
acted upon by a watery menstruum, either under the 
form of infusion or decoction. 

If practitioners have differed in opinion with regard 
to the effects of cinchona in phthisis, differences no 
less considerable have taken place with regard to ano- 
ther set of medicines, the vegetable balsams, as they 
have been called. These have derived the name of 
balsams from a supposed power of promoting the heal- 
ing of wounds and ulcers. At one time, many of them 
were highly extolled in pulmonary consumptions. Th? 



94 MODES OF CURE 

balsamum Giliadense, Canadense, Copaiva, and sevc 
ral others, have each had their day of fashion, and 
have each fallen into deserved neglect. Many argu- 
ments have been brought to prove, that the balsams 
and gummi-resinous substances which have by some 
been recommended in phthisis, as they possess a heat- 
ing and stimulating power, must be prejudicial in that 
disease. They have particularly been condemned by 
the late eminent Dr Fothergill, in a paper in the 
London Medical Observations, in which he brings 
many arguments to show, that the use of them in phthi- 
sis has been adopted on mistaken principles, and fol- 
lowed without due consideration; and he concludes, 
from his own observations in practice, that they arc 
prejudicial. His opinion respecting them has of late 
been very generally adopted. 

That in many cases they may have done harm, I 
do not deny; but those who condemn the use of them 
indiscriminately seem to me to carry the matter too 
far. In particular cases of consumption, I am dispos- 
ed to think favourably of some of them, and especially 
of that gummi-resinous substance, which has been 
denominated myrrh, — and which is the produce of a 
tree, with regard to the botanical history of which we 
are still much in the dark. Even since Dr Fother- 
gill's condemnation of the balsams, this article ha* 



IN PHTHISIS PULMONALE. 95 

been highly extolled in phthisis, by several accurate 
observers, particularly by Dr Simmons, in his valua- 
ble Treatise on Consumption. He considers it as coun- 
teracting the effects of absorbed ichorous pus, from 
its antiseptic powers; and that it does possess these i3 
universally allowed. Hebce, whatever bad effects 
it may have in other respect^, it may thus be of use; 
and the inconveniencies dreaded from its immediate 
action on the stomach, as heat\ng, may in some de- 
gree be obviated by giving it combined with a refrige- 
rant, nitre or supertartrate of potass. Accordingly, the 
gum-myrrh has been directed to be taken to the extent 
of twenty or thirty grains thrice a-day, united with an 
equal quantity of either of these articles. And the 
testimony of Dr Simmons, in support of its efficacy, 
has been confirmed by numerous observations ofDrs 
Griffiths, Fordyce, Saunders, and others. 

To their experience I can also add the result of ex- 
tensive observation in my own practice. For, although 
I can by no means represent it as having often produc- 
ed a cure, yet in some instances I think I have seen 
the best effects from it. I have used gum-myrrb fre- 
quently in all the three species of pulmonary consump- 
tion, but not in all of them with equal advantage. In 
the catarrhal phthisis, less benefit is to be derived 
from it than in the other two species. In the tuber- 



96 MODES OF CURL 

culous I have sometimes thought it was of service, 
but of all the modifications of the disease, I have found 
it most useful in the apostematous. In more than one 
instance, if I have not been much deceived, it has con- 
tributed very considerably to bring about a complete 
recovery. In such cases, therefore, I consider it as 
well entitled to a fair trial; and for my own part, at 
least, I have not observed any bad effects resulting 
from its use. 

In treating of balsams in phthisis, it may not, per- 
haps, be improper to mention another article, which, 
although a quack medicine, has of late been highly 
extolled by some regular practitioners, viz. that which 
has been sold under the name of Godbold/s balsam. 
The use of this article in phthisis I have had many 
opportunities of observing. Of its composition I know 
nothing: for, although the receipt sworn to and record- 
ed in Chancery, by the patentee, has been repeatedly 
published, yet no medical man, in the least acquainted 
with t\ie materia medica, will for a moment suppose, 
that it is prepared according to that specification. 
An ingenious chemist in Edinburgh has, indeed, 
bestowed a great deal of paias in analyzing Godbold's 
balsam, and sells, at a much lower price, a balsam 
'i- coas: ers to be very near; , if not precisely, 
the same wnnthatof Godboid; and as far as I have 



IN PHTHISIS PULMONALIS. 97 

been able to observe, the effects of both are nearly 
the same. Of both these articles I am inclined to 
think rather favourably; but I can by no means say 
much for either. I have met with no instance, in 
which, by either, a cure of phthisis has been obtained; 
nordo I believe that either of them will cure phthisis 
in any case. I have indeed met with different cases, 
where catarrh, with alarming appearances, has been 
entirely removed during their use; and from such cases 
being mistaken for phthisis, they probably derive their 
present high reputation. But all the benefit I have 
ever observed from them in any case is merely the 
mitigation of cough. 

Among other active medicines, recourse has been 
had, in phthisis, to mercury, to sarsaparilla, and to 
mezereon; but I have never witnessed benefit from 
any of them, and if they ever do any good, I am in- 
clined to think, it will only be in those cases where 
phthisis has been excited by a preceding venereal affec- 
tion, and where the virus of syphilis has not been fully 
overcome. 



I can also, from my own experience, say very little 
in favour either of the tussilago farfara, or of the lichen 
islandicus. Any good effect which has ever been observ- 
ed from these, I am inclined to attribute entirely to the 



98 MODES OF CURL 

vegetable mucilage which they contain, tending to alia) 
cough, by operating as a demulcent. Of the cicuta 
or hemlock, the conium maculatum of Lmsaxs, I am 
inclined to think more favourably. With patients of a 
scrofulous habit, subjected to symptoms threatening 
tuberculous phthisis, I have sometimes imagined that 
the conium, in conjunction with cinchona, has had a 
good effect in preventing the occurrence of phthisis. 

Sea-water, and mineral waters, particularly those oi 
the sulphureous kind, and the Bristol waters, have by 
some been strongly recommended, even in the confirm- 
ed stages of tuberculous phthisis, from the affinity 
which that modification of the disease bears to scrofula. 
In the prevention of this species, they may perhaps do 
some good. But after tuberculous phthisis is distinctly 
marked, although in some respects they may seem to 
be indicated, yet in others their operation is unfavour- 
able, particularly if taken to such an extent as to pro- 
duce a purgative effect. Accordingly, they are now 
very little if at all employed after phthisis can with 
certainty be affirmed to exist. 

While, for resolving tubercles ©r healing ulcerations 
in the lungs, many medicines have been taken inter- 
nally, some modes of cure have been recommended, 
with the view of acting topically on the diseased part? 



IN PHTHISIS PULMONALE. 



99 



in this way, different articles have been directed to 
be inhaled into the lungs, under the form of vapour. 
From applications in this way, very high expectations 
have been held out by some eminent practitioners, 
particularly the late Dr Beddoes; and indeed it was 
entirely with the view of determining their efficacy, 
that he established what he styled the Pneumatic In- 
stitution at Clifton. The inhalation of a larger pro- 
portion of carbonic acid gas than is usually con- 
tained in common atmospheric air, has particularly 
been advised; and although it be well known that 
the inspiration of it in a concentrated state proves 
suddenly fatal even to the human species, yet, when 
it is diffused in the atmospheric air inspired, it may be 
taken with impunity, and it has been directed in phthi- 
sis, with a view to its antiseptic power. But even if it 
were to operate as a very powerful antiseptic at the 
ulcerated parts, yet it is much to be doubted how far it 
would have any influence as curing phthisis. It might 
indeed perhaps in some degree correct that putrid mat- 
ter already separated from the ulcers in the lungs; and 
thus might mitigate for a little the violence of the affec- 
tion even of the hectic fever. But I am inclined to 
think, that nothing is to be expected from it either as 
giving ulcers in the lungs a tendency to heal ? or in the 
removal of tubercles 



100 MODES OF CURE 

Of this practice, however, I can say nothing frorn 
my own experience; and I have heard nothing from 
others tending to confirm its success. I have not even 
been informed of a single reputed cure of phthisis at 
the Pneumatic Institution,* where this practice may be 
supposed to be employed in the most efficacious 
manner. 

A similar remark may perhaps be made respecting 
the inefficacy of resinous effluvia introduced into the 
lungs, when obtained by burning tar, rosin, or similar 
substances. These vapours also have been recommend- 
ed^ and I have known them tried in several instances; 
but I never could observe any good effect from them. 
On the contrary, by exciting cough, I have often seet: 
them productive of very great inconvenience. That 
in some instances they may have had the effect of in- 
ducing the adhesive inflammation, incases ofaposte- 
matous phthisis, I would not deny; and hence I would 
by no means represent them as altogether improper, 
But I am inclined to think, that they will seldom be 
attended with much advantage, and that often they will 
be productive of very great inconvenience. 

Among other vapours taken in by inspiration, that 
which is exhaled from a cow-house has been strongly 
recommended by some practitioners. To obtain this. 



IN PHTHISIS PULMONALE 101 

it has been enjoined to phthisical patients to live in the 
midst of cows; to be in that company not only during 
the day, but during the night also, the patient having 
with that intention a proper bed placed in the cow* 
house. This mode of cure has been highly extolled 
by one practitioner, who has published the case of a 
French lady of quality, in which it is said to have been 
attended with a most wonderful effect. But I have 
never seen this practice tried, and I must own I have 
no confidence in it. I fear much, that any phthisical 
patieni submitting to live in a cow-house would be 
subjected to great inconvenience, without any material 
benefit 

If the inhalation of any vapour, which has hitherto 
been recommended, shall be found advantageous in 
phthisis, I should be inclined to think, that benefit 
might be expected from the vapour of sulphuric aether. 
This has been highly extolled by one practitioner of 
eminence, Dr Richard Pearson of London. In a 
paper of his, published in the Edinburgh Annals of 
Medicine 1796, a particular account is given of this 
practice; and he observes, that he has found the saluta- 
ry operation of sulphuric aether applied to the lungs, 
under the form of vapour, to be greatly promoted by 
several volatile substances that are soluble in it; but 
by none more than the conium maculatum. By ma- 

i2 



102 MODES OF CURE 

cerating a sufficient quantity of the dried leaves ot the 
hemlock in sulphuric aether, for the space of three or 
four days, or at most of a week, and by occasionally 
shaking them together, a very saturated tincture is obtain- 
ed. The proportion which Dr Pearson has in general us- 
ed was about half a drachm of the powdered leaves of 
the conium to an ounce of the aether. One or two tea 
spoonfuls, either of pure aether, or of this impregnated 
fluid, is put into a tea-cup or wine glass, and held up to 
the mouth. The patient is directed to draw in the vapour 
which arises from it with the breath, continuing it till 
the whole tea-spoonful or two of aether be evaporated. 
This process he directs to be repeated three, four, or 
even five times in the course of a day. for a month or 
six weeks, according to circumstances. From this he 
affirms that the best effects will often be obtained. He 
does not indeed recommend it in every modification of 
phthisis; but he considers it as best suited to the florid. 
or what is commonly termed the scrofidov.s consump- 
tion. 

Since I first read Dr Pearson's publication on this 
subject, I have repeatedly directed to patients the in- 
halation, both of pure aether, and of aether impregnated 
with hemlock; and in different cases it has appeared 
to me to be productive of considerable beuefit. It has 
often had very great influence in relieving both the dysp- 



IN PHTHI9IS PULMONALIS. 103 

noea and cough. But I have found it particularly use- 
ful as promoting expectoration, in those cases where vis- 
cid mucus, mixed with a large proportion of purulent 
matter, could not be discharged from the lungs without 
very distressing cough. I have never, indeed, found 
the employment of it followed by a cure, either in the 
catarrhal, or any other species of phthisis; yet, from 
what I have seen, I am convinced, that, in different 
conditions of phthisis, it may be employed with advan- 
tage. i 

Another practice recommended in phthisis, the effi- 
cacy of which has been supposed to depend on certain 
vapours, is the bano de tiera, or earth baths, as they 
have commonly been called, where the patient is con- 
fined for some time in a pit newly dug in the earth. This 
practice has in particular, been recommended by Dr 
Simmons, as well as several other eminent writers; and 
he endeavours to account for its efficacy, from the anti- 
septic powers of the exhalations from the earth, which 
will thus have an opportunity of being absorbed at the 
surface of the body. The earth-bath I have never di- 
rected for any patient; nor have I ever witnessed the 
employment of it. But about thirty years ago it was 
tried in a few cases at Edinburgh; and according to the 
information which I have received, in all these it was 
attended with a bad effect, always aggravating the 



104 MODES OF CURE 

cough, and not unfrequently inducing a hectic parox- 
ysm. When it was employed even during the warmest 
weather in summer, it excited a distressing sense of 
coldness. 

After what has now been said of some of the prin- 
cipal remedies which have been recommended in phthi- 
sis, I shall next offer a few remarks concerning regi- 
men in this disease. Perhaps a greater number of 
cures in phthisis have been effected by regimen than by 
medicine, especially if under the head of regimen be 
included, not merely diet, but air, exercise, and similar 
circumstances. To treat of all these, however, at 
length, would require a very extensive discussion. All, 
therefore, that is now proposed is, to make a few re- 
marks on some of the principal circumstances. 

It has been but too common to prescribe the same 
diet in every species of phthisis pulmonalis, and at eve- 
ry period of the disease. By many, those labouring 
under phthisis have been altogether interdicted from 
the use of animal food. They have either been entire- 
ly confined to vegetable diet; or at the utmost have 
been indulged with a small proportion of milk, — a fluid 
which, as an article of diet, may be considered as in 
some degree intermediate between the vegetable and 
animal kingdom. That this plan may in some case^ 



IN PHTHISIS PULMONALIS. 1U5 

be proper, I would not deny; but I have no doubt in 
asserting, that such starvation has often been attended 
with a bad effect, and has hastened the death of the 
patient. The very extraordinary doctrine lately contend- 
ed for by a remarkable London physician, DrLAMBE, 
is too absurd to deserve any refutation, notwithstanding 
the parade of learning with which he attempts to sup- 
port it. 

Others, on the contrary, observing the great loss of 
strength which occurs in phthisis, have absurdly sup- 
posed, that it is a disease altogether depending on a 
high degree of debility, With the view of combating 
this, they have recommended a very full diet, of ths 
most stimulating food. But from this, there can be m 
doubt, that equally pernicious effects have resulted, as 
from the opposite plan of mere vegetable diet. 

It is unnecessary to observe, that the diet best accom- 
modated to the human species is of a mixed nature. 
With almost all nations the articles of diet which they 
employ are taken partly from the animal and partly 
from the vegetable kingdom. The former, however, 
is upon the whole more stimulant than the latter, which 
often exerts even a refrigerant effect on the human 
system. But besides both animal and vegetable sub- 
stances, the food of all the human species, at the very 



106 MODES OF CURE 

earliest period of life, consists principally of an article 
which may be considered as in some degree intermedi- 
ate between the vegetable and animal kingdom, viz. 
milk. For although it be immediately afforded from 
the breasts of the mammalia, yet it does not, like other 
animal fluids, and those animal solids used in diet, run 
directly into the putrefactive process, but is, in the first 
instance, like vegetables, subjected to an acescent fer- 
mentation. Milk, however, furnishes a mild and nutri- 
tious aliment, not only to infants, but to adults. 

In judging of that diet which is best suited to parti- 
cular conditions of certain diseases, due attention must 
be paid to its effects upon the system. These effects 
are chiefly of two kinds: They either arise from the 
immediate influence which -alimentary matters exert 
upon the stomach, or from the influence which they 
have as entering the mass of circulating fluids. With 
regard to the effects arising from an action on the sto- 
mach, alimentary articles differ from each other, as be- 
ing more or less stimulant. From the immediate in- 
fluence which some of them exert, in consequence of 
their action on the sentient extremities of the nerves of 
the stomach, their stimulant effect is extended over the 
whole system, and is clearly indicated, both by an aug- 
mentation of the celerity and momentum of the pulse, 
and bv an increased sense of heat. Other articles. 



IN PHTHISI3 PULMONALE. 107 

again, are of so mild and bland a nature, that they pro- 
duce no obvious effect; while there are certain articles 
which evidently demonstrate their possessing what have 
been called refrigerant qualities, by inducing both a sense 
of coldness, and diminishing the impetuous circulation. 

From the influence of different alimentary matters, 
as entering the system, their effects vary chiefly as they 
are more or less nutritious. Some articles certainly af- 
ford a much larger proportion of chyle than others, when 
taken to the same extent, or to the same weight; and 
some articles yield a much richer and more nutritious 
chyle than others. For there is every reason to believe 
that the same varieties may take place with regard to 
the chyle of animals as with regard to their milk. The 
last-mentioned of these fluids, in the case of that ani- 
mal the milk of which is chiefly employed as an 
article of diet, the cow, is well known to be much af- 
fected by the food on which she is supported: hence 
the superiority of the milk of a cow fed on old pasture 
over that of the very same animal when fed on turnip. 
Nay, there can be no doubt, that, by the copious in- 
troduction of water into the stomach of the animal, 
the watery part of a cow's milk bears a much greater 
proportion to the oleaginous and coagulable parts, to 
the butter and cheese, than it does when she is re- 
strained to a small quantity of fluid. Accordingly, 



1QS MODES OF CURE 

it has been alleged, that certain dealers in milk em- 
ploy artifical means of exciting thirst in their cows, 
that the animal may be induced to drink a large quan- 
tity of water. In consequence of this, a larger quan- 
tity of watery milk is drawn from the animal, the na- 
tural milk being as it were watered in her udder. 
Thus, when milk is even fresh drawn from the cow 
at the door of the patient, it may still, strictly speak- 
ing, be but milk and water. 

From what has now been said, it follows, that the 
articles commonly employed for nourishment, may 
w T ith propriety be divided into four kiuds of diet: the 
stimulant, the refrigerant, the nutritious, and the spare. 
In a great majority of those diseases requiring a spare 
diet, particularly those accompanied with plethora, and 
occurring in the sanguine temperament, as in haemor- 
rhagies, inflammations, Gr the like, it is proper that 
the diet should not only be of the spare, but that it 
should also be of the refrigerant kind. On the other 
hand, in most of those .diseases in which a stimulant 
diet is indicated, where it is necessary to support the 
impetus of circulation, and to counteract a state of 
debility and exhaustion, the diet, while it is stimulant, 
should also be nutritious. Hence, it has with many 
been a general rule always to combine the refrigerant 
with the spare diet, and the stimulant with the nutritious 



IN PHTHISIS PULMONALIS. 109 

This general rule has in particular been often observed 
in giving directions with regard to the diet o£ phthisical 
patients; and in my opinion, the observance of it has of- 
ten done much mischief. It has been supposed by some, 
thatevenwhen a phthisical patient is in the most exhaust- 
ed condition, and in a state of the utmost debility, there 
still prevails in the system an inflammatory tendency; 
and that the quickness of the pulse, even when it is 
the weakest and most commpressible, still contra- 
indicates the employment of any food, either stimulant 
of even nutritious. Accordingly, while to patknts, in a 
state of the utmost exhaustion and emaciation, as marked 
by the fades Hippocratica, they have directed repeated 
small bleedings, they have also strictly enjoined the 
the most spare and refrigerant diet. With this view they 
have directed that the whole aliment employed should 
.be entirely taken from the vegetable kingdom; and 
they have recommended principally, not the most nu- 
tritious vegetables, as the farinaceous grains and muci- 
laginous roots, but those of the refrigerant kind, as the 
acescent fruits, and cooling laxative greens. From 
these they have concluded, that, while such support 
may be afforded to the system as will prevent great 
uneasiness from hunger, nothing is to be apprehended 
as increasing a plethoric state; and from the influence 
which these refrigerant vegetables exert upon the sto- 
mach, they have at the same time expected, that they 






110 MODES OF CURE 

would prove useful, as diminishing the celerity of the 
pulse, anq^the impetus of the blood. 

From these circumstances, such diet may seem par- 
ticularly adapted to the earliest stages of phthisis in 
some cases, especially where there is reason to dread 
that either frequent haemorrhagies from the lungs, or an 
active inflammation within the chest,wiil terminate in an 
apostema; for, in order to prevent such a termination, 
while a considerable discharge by blood-letting is requi- 
site, it is certainly proper to avoid those articles which 
can furnish a large supply of rich chyle, even although 
they should be, like milk, of the very mildest nature. 
Hence, in certain stages of the apostematous phthisis, 
it may be proper to enjoin a diet entirely of refrige- 
rant vegetables; or, when these do not satisfy hunger, 
it may be proper to allow no other addition to the ve- 
getable diet than a small quantity of milk, and that, 
too, not in its richest state, but as deprived of its most 
nutritious part. Hence, some have advised butter- 
milk in preference to fresh drawn cow's milk, or have 
directed that the fr(.*i cow's milk should be employed 
somewhat diluted, and with the addition of a small 
quantity of sugar. By this means, in its sensible 
qualities, and probably also in its effects on the system, 
it will approach nearly to ass's-milk; for there can be 
no doubt, that ass's-milk, and even mareVmilk. 



IN PHTHISIS PULM0NAL1S. Ill 

diner principally fromcow's-milk, in containing a less 
proportion of the butyraceous and coagulable or cheesy 
matter, and a larger proportion of the saccharine, or, 
perhaps more properly, the saline part. But, although 
this diet may be well fitted for the beginning, or rather 
for the prevention of apostema, yet, after an apostema is 
really formed, and after, by the bursting of that apos- 
tema, an opportunity is afforded for a free discharge 
of purulent matter, it is no longer adviseable. On the 
contrary, a more nutritions diet is essentially necessary 
for giving the ulcer a chance of healing, by which alone 
a recovery can be expected. 

In the incipient state of the catarrhal phthisis, the 
diet should be nearly the same as in the beginning of 
the apostematous; for here also there is in some de- 
gree an inflammatory affection of the internal surface 
of the lungs. Hence, whatever will much augment 
the impetus of circulation is to be avoided. But even 
in the incipient state of catarrhal phthisis, there are 
not the same reasons for wishing to diminish the im- 
petus of circulation as in the apostematous; and when 
the patient is much debilitated, the system requires to 
be recruited and supported. Hence, though stimulant 
articles are to be shunned, yet advantage may be de- 
rived from nutritious aliment; and to this species of 
phthisis, even from the commencement* a more libe- 



112 MODES OF CURE 

ral diet is well suited. Where milk- agrees with the 
stomach, it is as little stimulant, and often as easily 
digested, as any vegetable; and accordingly, in dif- 
ferent forms, it may constitute a considerable part of 
the diet with advantage. 

Respecting the proper diet in tuberculous phthisis, 
much difference in opiuion has taken place. On the 
one hand, it has been contended, that here the greatest 
danger is to be dreaJed from inflammation and con- 
sequent suppuration at the tubercles; and on this ground, 
the most spare and the most refrigerant diet has been 
strictly enjoined. But, on the other hand, it has been 
alleged, that this modification of the disease derives 
its origin from a scrofulous constitution; and that, to 
other modifications of scrofula, low diet is by no means 
best accommodated. On the contrary, there can be 
little doubt, that scrofula is often produced by a very 
poor and meagre w r ay of life, and that it is a much 
more common disease with children who are half starv- 
ed, than with those who are well fed. On this foot- 
ing, therefore, by some, a generous, and even a stimu- 
lant diet, has been advised. Of these two opposite 
opinions, neither, perhaps, is to be altogether adopted. 

In the tuberculous, as well as in other species of 
phthisis, in the incipient state, it is unquestionably an 



IN PHTHISIS PULMONALIS. 113 

object of importance to avoid inflammation; but, not- 
withstanding every precaution, inflammation at the 
tubercles, terminating in ill-conditioned suppuration, 
will often occur; and when it does take place, it is only 
by a certain degree of vigour in the system, that proper 
suppurative and adhesive inflammations can be induc- 
ed. The healing of tuberculous ulcers in the lungs, 
as well as of scrofulous sores at other parts, is only to 
be expected from recruiting and giving vigour to the 
system. In this state of the disease, therefore, a nu- 
tritious diet is naturally indicated; and, indeed, the 
evident marks of exhaustion point out the propriety of 
a due supply. Besides these particulars, a liberal and 
nutritious diet is often indicated in this species of 
phthisis by the feelings of the patient; for it is by no 
means uncommon to observe even a craving for animal 
food; and it may be remarked, that in very rare in- 
stances only are such calls of nature entirely to be 
neglected. In every case some indulgence to the 
cravings of nature is perhaps adviseable; and the 
practitioner should form his judgment, not from pre- 
conceived opinion, but from the effects which he ob- 
serves in any particular case after a trial is made of 
those articles for tvhich a craving occurs. Judging 
from my own experience, I have no hesitation in as- 
serting, that, in most instances of tuberculous phthisis, 
and during almost the whole course of the disease, a 
k2 



H4 MODES OF CURE. 

nutritious diet may be employed with great advantage; 
and that, on the contrary, a rapid progress of the affec- 
tion to a fatal conclusion, is the consequence of a very 
abstemious and refrigerant diet. 

While, however, I am thus an advocate for a nutri- 
tious, I would by no means advise a stimulant diet for 
patients subjected to tuberculous phthisis. A great 
part of the diet in this species also may, with advantage, 
consist of milk. The animal food selected should be 
nutritious, but at the same time mild. Animal sub- 
stances of an alkalescent nature are to be avoided. 
The animal food employed should always be plainly 
dressed. It may be thus taken to some extent in a solid 
state; but it should be chiefly used under the form of 
good animal broths or animal jellies. 

The same general regulations which have been given 
with respect to diet, in some degree also apply to the drink 
of phthisical patients. To a certain extent, the natu- 
ral cravings of the patient are to be attended to, and 
the quantity of drink is to be regulated by the degree 
of thirst which may take place. From the use of mere 
diluents quenching thirst, no inconvenience will arise. 
The appetite of thirst may be freely indulged, even 
during the time of colliquative sweats and colliquative 
diarrhoea. Care need only be taken to direct such 



IN PHTHISIS PULMONALIS. ttj 

iluids as have not a particular tendency to increase 
these evacuations. Nothing is to be dreaded from 
pure spring- water taken cold from the fountain. No 
supposition is more groundless than that of viewing 
pure spring-water as a poison; and the purification of 
it by distillation, which some have recommended, in 
reality injures it as a diluent for quenching thirst in 
place of improving it. With profuse sweatings, how- 
ever, acidulated drinks are to be preferred to pure 
water; and with diarrhoea, drinks of a mucilagi- 
nous nature ; but toast water, and milk diluted with 
water, maybe employed in almost any case. In certain 
instances, it. may be proper, in conjunction with dilu- 
ents, to mitigate thirst by acescent fruits, oranges, ta~ 
marinds, or the like. Drinks of the cordial and stimu- 
lant kind are rarely admissible; but when there is a 
strong craving for these, they should not altogether be 
denied. The safest and best that can be employed is 
wine diluted under the form of negus. I can recollect 
only one instance where the patient, a young girl, had 
a craving for spirits, — a liquor to which in health she 
had been altogether unaccustomed. In that case the 
patient was indulged in the use of diluted spirits to a 
small extent; but the disease in a short time had a fatal 
termination; the spirits, so far as I could judge, produ- 
cing neither a good nor bad effect. 

If attention be necessary to the aliment of patients 
labouring under phthisis, it is no less requisite to the 






116 ;>IODES OF (JURE 

air Tvbich they breathe. It has often been thought, 
that very great benefit in phthisis has been obtained by 
a change of air, even from one part of Britain to ano- 
ther. Many have attributed the good effects which 
have followed removal from other parts of Britain to 
Bristol, much more to the patient's breathing the pure 
air of Clifton, than to any efficacy in the Bristol waters; 
but no more peculiar virtue can, in my opinion, be at- 
tributed to the air than to the water of Bristol. There 
can, however, be no doubt, that it is beneficial to a 
phthisical patient, to be removed from the air of towns, 
contaminated by the smoke of many fires, and from any 
situation even in the country where the atmosphere is 
peculiarly cold and moist. When removed to warmer 
climates, a moist atmosphere, and a hot situation conjoin- 
ed with moisture, or with noxious exhalations, are equal- 
ly to be avoided. A pure and a dry atmosphere, as far as it 
can be obtained, is to be selected: And if, before the com- 
mencement of the disease, the patient has come from a 
healthy situation in the country to live in a large town, a 
removal to his native air will in general be advantageous, 
not merely as affording a purer atmospbere, but as put- 
ting it in his power to enjoy amusement with the com- 
panions of his youth, and have perhaps the attendance 
of affectionate relations. 



But while pure and dry air are sought for. the tern- 






IN PHTHISIS PULMONALIS. 117 

perature of the air is not unworthy of attention. Ex- 
tremes of heat and cold, whether in the open air or in 
the chamber in which the patient is kept, are equally 
to be shunned; but of the two, from the extreme of 
cold most is to be apprehended. The winter cold of 
the external air in Britain can seldom be borne with- 
out injury; and where circumstances prevent a change 
of climate, it is. often advantageous even for a patient, 
although he may have sufficient strength to take exer- 
cise in the open air, to confine himself to the house dur- 
ing the coldest months in the winter, and never to al- 
low the atmosphere of his room to be under forty-eight 
degrees, or what is commonly marked temperate on 
Fahrenheit's scale. 

But confinement to the house in Britain is not more 
necessary as a means of guarding against cold than 
against the sudden vicissitudes of the weather. Hence 
the advantage of removing for the winter months to a 
more southern and more steady climate. It has been 
advised by some, that phthisical patients should reside 
near the sea. In such a situation, in every climate, 
both the cold of winter, and heat of summer, are some- 
what moderated. But it has been imagined, that be- 
sides the temperature, peculiar advantage may be deriv- 
ed from sea-air. Of late, however, a very different 
doctrine has been held. Dr Carmichael Smyth, in 



118 MCi ;re 

a late valuable treatise on consumptions, alleges, both 
from his own experience and that of other eminent 
practitioners, that sea-ai: generally prejudicial 

to phthisical patients. I must, however, observe, that, 
in my own practice. I have seen nothing tending to con- 
firm this opinion. Whether near the sea. or at a dis- 
tance from it.whatis chiefly m be sought for is a comfort - 
iblesitnati the patient may breathe pure air. 

A::er what has been said of the temperature of the 
is hardly necessary to add any thing respecting 
clothing. This must be entirely accommodated to the 
: n of the patient. While care is taken to guard 
against an uneasy sense of cold, it is equally nee 
to shun what will induce sweating; and the patient 
should neither be op 

nor fatigued with the weight : i ipparel. Tut 

aimed at should there;. in moderate 

warmth, combined with lightness: and arpose 

it will - il be adv? thin flannel 

on cloth mxt the skin, re particularly 

-.ial. where the pa: 

- ire. they prevent that sense of coldness 
ma linen shirt, while at the same time 
they support uniform circulation at the surface. 

:be disch:: attention wmA 



IN PHTHISIS PULMONALIS, 119 

also be paid to the discharge by the bowels. Inconve- 
nience always arises from a state of constipation. But 
still more is to be dreaded from the induction of diar- 
rhoea. When constipation occurs, therefore, the most 
gentle laxatives should alone be employed; and it is 
much more desirable to obtain a regular discharge by 
diet than by any medicines. 

While it is of importance to regulate the discharges 
from the body, so it is also of very great consequence 
to regulate the passions of the mind. The state of 
mind should be kept as equable as possible. In this 
disease, however, more perhaps is to be dreaded from 
the exhilarating than from the depressing passions, 
For it has been marked as a peculiarity of phthisis, that 
the patient is almost never apprehensive of danger, 
During the febrile accessions in particular, in place of 
that anxietasfebrilis, which is the constant attendant of 
idiopathic fever, there is often such a flow of spirits, 
as to require being moderated; or at least, it is necessa- 
ry to shun what will tend farther to exhilarate. At the 
same time, it is equally necessary to avoid what will 
depress the patient; and even where there is very faint 
expectation of recovery, the chance of such an event 
will be diminished, by endeavouring to make the pa- 
tient fully sensible of his own danger. 



120 MODES OF CURL 

Exercise in various forms has been strongly enjoin- 
ed as a mode of cure in every different species oi 
pulmonary consumption. Although there is very lit- 
tle probability that it will remove ulceration, either 
from a tubercle or apostema, yet it is so much connect- 
ed with the support of the general health, that without 
it, other practices can have much less effect. It should 
always, therefore, be advised, wherever the strength of 
the patient and the state of the weather will admit of 
its being taken; and it should be carried as far as he 
is easily able to bear without fatigue. Of all the modes 
of exercise, where the patient has sufficient strength, 
none is, perhaps, preferable to walking. It tends to 
support equal and natural heat, and to promote regular 
circulation through the whole body, even to the infe- 
rior extremities. But it must be allowed, that this ac- 
tive exercise is much more apt to induce fatigue, than 
passive exercise, mere motion, or modes of gestation, 
as they have been called. Of all modes of gestation, 
gentle riding on horseback, as giving exposure to free 
and fresh air, is, perhaps, the best. Where the patient 
wants strength for this, advantage may still be deriv- 
ed from riding in a carriage, or even from being car- 
ried out in a chair. 

A mode of motion still more gentle than either of 
these mav be obtained from sailing. This, indeed. 



IN PHTHISIS PULMONALIS. 121 

can hardly be called exercise, though there be a very 
considerable degree of motion; and one eminent prac- 
titioner, Dr Carmichael Smyth, in a late treatise on 
the subject, is of opinion that mere motion is much su- 
perior to any exercise. That constant motion, without 
fatigue, may thus be obtained, is certainly true. But 
notwithstanding this, I would by no means recommend 
a long sea-voyage, for obtaining such permanent mo- 
tion. In long voyages, a patient may necessarily ex- 
pect to be sometimes subjected to bad weather; and 
on such occasions a weak invalid is unavoidably ex- 
posed to numberless inconveniencies. To obtain, 
therefore, the good effects of this mode of motion, 
without these inconveniencies, I would prefer a situa- 
tion near the sea, or some navigable lake, where sail- 
ing might be employed every day when the state of the 
weather was favourable. 

As possessing all the advantages of that motion 
which is given by sailing, without almost any bodily 
exertion whatever, Dr Carmichael Smyth, in a late 
publication on the effects of swinging employed as a 
remedy in pulmonary consumption and hectic fever, 
has very strongly recommended that motion which 
may be given to the body in a chair properly suspend- 
ed. This mode of motion may in most situations be 
with advantage employed either in the open air or in 

L 



122 MODES OF CURE 

any large room, when exposure to the external atmo- 
sphere is judged improper. I have accordingly di- 
rected it in many cases, and I have been led to con- 
clude, that it was used not altogether without advan- 
tage. I consider it as, upon the whole, preferable 
to the motion which is given by a spring-chair, or 
spring -deal. But it has by no means answered in 
my practice those expectations, which, from the peru- 
rusal of Dr Smyth's account, I was led to expect from 
it; and of all the modes of exercise which have been 
advised, judging from my own observation, I am in- 
clined to consider walking on foot, as, upon the whole, 
productive of the greatest advantages. 

Having thus stated my sentiments respecting the re- 
medies and regimen which have been most highly 
recommended in phthisis pulmonalis, and from which, 
when properly adapted to the circumstances of 
the case, there is, in my opinion, the best chance 
of recovery, I shall conclude my observations with a 
very few remarks on the means of obviating urgent 
symptoms. 

It is a fortunate circumstance for the feelings of 
every medical practitioner, that, even in those diseases 
where the prospect of recovery is the most faint, and 
where there is next to certainty of an approaching dis- 



IN PHTHISIS PULMONALIS. 128 

solution in no long time, he still has it often in his 
power to protract the period of life, and to alleviate the 
distress of his patient. In many cases of phthisis, this is 
all that he can reasonably expect to accomplish. The 
means by which it is to be accomplished must be much 
varied according to circumstances; and the success of 
the remedies which are employed to obviate urgent 
symptoms must depend very much on the prudence and 
penetration of the physician, exerted at the moment. It 
is, therefore, altogether unnecessary to treat of these at 
any length; and I shall here merely take notice of three 
symptoms, which, before a fatal termination takes place, 
are very distressing in most instances. These are, the 
colliquative sweats, the diarrhoea, and the cough. 

Colliquative sweats can hardly, perhaps, be called 
a distressing symptom. They are productive of no 
pain, and of little uneasiness to the patient. They do 
not even prevent sleep, but they tend very much to 
debilitate the patient; and, perhaps more than any 
other circumstance, have the effect, even at an early pe- 
riod of the disease, of inducing the loss of fat and of 
flesh, and even that appearance which marks the ut- 
most degree of exhaustion, the fades Hippocratica. By 
the loss of strength, however, the chance of recovery 
is certainly vere much diminished. Hence, though a 
free cuticular discharge is often a means of alleviating 



124 Modes of cure 

cough, and of removing catarrh threatening phthisb. 
yet profuse sweatings in such circumstances are always 
to be dreaded; and where the patient complains much 
of loss of strength, are always to be moderated. 
For this purpose, gentle means of checking them must 
be employed. They may always be stopped by the ex- 
posure of the surface to cold air; but from this much 
greater evil than benefit will in most instances result 
To obtain good effects from the action of cold upon 
the surface great prudence is necessary. The bed- 
clothes are to be made, gradually only, thinner and 
lighter; and the same prudence is to be observed in 
thinning the dress of the patient. Nothing, however, 
in my opinion, tends more to counteract this symptom 
with safety than substituting for thick flannel the use 
of cotton-cloth. Cotton shirts and sheets are equally 
useful in absorbing sweat as woollen next the skin; and 
they give comfortable warmth, without the same de- 
gree of heat which arises from flannel. In the way 
of medicine, various articles may be employed; but 
I have found nothing so advantageous as the prudent 
use of the sulphuric acid properly diluted. 

The diarrhoea, which often occurs in phthisis, can 
in no degree be supposed to contribute to the recovery 
of the patient. It is, indeed, of advantage in every 
instance of phthisis to prevent costiveness; and it is 



IN PHTHISIS PULMONALIS. 



125 



always a desirable circumstance to keep the bowels 
rather loose than otherwise; but this should be at- 
tempted to be obtained rather by diet than by medicines. 
When medicines become necessary, the most gentle 
emollient cathartics are to be employed; for it ought 
to be the object of the practitioner, particularly in the 
tuberculous phthisis, merely to evacuate from the 
alimentary canal, and not from the system. When 
catharisis is once induced, it is not always easily stop- 
ped; and frequent discharges, under the form of stooj, 
weaken the system little less than profuse sweating* 
When diarrhoea, therefore, occurs spontaneously, it is 
always to be stopped, or at least moderated; but this 
also should be done rather by diet than by medicine; 
by shunning the use of those articles which are 
observed to increase it, and by employing what are 
found to moderate it. This is often obtained by mild 
mucilaginous broths, particularly veal broth, or melt- 
ed calf-foot jelly, and by the use of rice in different 
forms. Where medicines are necessary, I have found 
nothing better than the extractum catechu, eiiher 
under the form of electuary or infusion, adding such 
a proportion of the tincture of opium as the circum« 
stances of the case may admit or require. 

Of all the symptoms which require to be mitigated, 
there is none which more frequently demands the at- 



126 MODES OF CURE 

tention of the practitioner than the cougb. The actios 
of coughing, as has formerly been observed, is often 
necessary in the apostematous phthisis, for discharging 
from the lungs great quantities of purulent matter; and 
the suppression of that discharge is often immediately 
productive of very great inconvenience; but unless as 
tending to evacuate either their purulent or mucaginous 
matter from the lungs, it is never beneficial; and it is 
often highly distressing to the patient, both during day 
and night, even when it occurs under the form of tussi- 
cula merely, in the tuberculous phthisis. The employ- 
ment, therefore, of such articles as will tend to mitigate 
it is often necessary. For this purpose, an almost 
infinite variety of articles, either of the demulcent or 
sedative kind, may be employed with advantage. Even 
when it is altogether impossible to remove that irrita- 
tion which induces the convulsive action termed cough- 
ing, the effects of the irritation may yet be often sus- 
pended or diminished, and that by substances possess- 
ing a sedative power, acting either on the fauces, or 
on the system in general. Of all these substances, 
none is so useful or so powerful as opium, which, in- 
deed, I am inclined to consider as the most valuable 
medicine yet discovered; for, to use the words of the 
illustrious Sydenham, Sine Mo manca sit et claudicet 
medicina; and judiciously administered< according to 



IN PHTHISIS PULMONALIS. 12"/ 

circumstances, it may be productive of the greatest ad- 
vantage. 

But opium, valuable as it is, can by no means be 
represented as free from inconvenience in this disease. 
There are some individuals, with whom, from peculi- 
arity of constitution, it always disagrees, and who can- 
not employ it, even in a very small quantity, without 
great inconvenience, confusion of head, vertigo, sick- 
ness at stomach, vomiting, and various other distressing 
symptoms. Hence, recourse has been had to a variety 
of other sedatives, both with the view of allaying inor- 
dinate action, and of procuring sleep. Where opium 
cannot be employed, different articles of this kind, par- 
ticularly the preparations of the hyoscyamus niger, 
and humulus lupulus, have often beeen used with ad- 
vantage; but of all the substitutes for opium which I 
have ever employed in practice, I have found none from 
which I have seen so great benefit, as from the prepara- 
tions formed from the inspissated white juice of the com- 
mon garden lettuce. Ever since the days of Galen, 
among the Romans, who employed it as a soporific in his 
own case, this article, like the papaver somniferum, and 
many other plants yielding a milky juice, has been known 
to possess a power of inducing sleep; but for a long time, 
although constantly cultivated as a salad, it has been 
almost entirely neglected as a soporific. A few years 



12.5 MODES OP CURE 

ago, some circumstances drew my attention to this ar- 
ticle; and I lately published, in the Memoirs of the 
Caledonian Horticultural Society, an account of differ- 
ent trials which I had made with it. My intention 
was to call the attention of industrious gardeners to 
this subject as an article of trade. These trials I shall 
not here repeat, but only observe, that of all the medi- 
cines which I have employed for alleviating cough in 
phthisis, and indeed as a sedative in many other dis- 
eases, next to opium, I have found no article so bene- 
ficial as that substance, which some have lately deno- 
minated lettuce opium, and which I termed lactuca- 
rium. But of this article, a more full account is given 
in the Appendix. And in the present edition, I have 
been enabled to enrich that Appendix, by communica- 
tions from different friends, on the preparation and use 
of lactucarium. 

Since the first edition of this short treatise was pre- 
sented to the public, phthisis pulmonalis has been the 
subject of several different interesting publications; and 
I may particularly mention, as well deserving notice, 
one by Dr Henry Herbert Southey, of London, 
Physician to the Westminster Hospital, entitled 
Observations on Pulmonary Consumption; and another 
by Dr William Barrow of Liverpool, entitled Re- 
searches on Pulmonary Phthisis, fram the French of .1/ 



£N PHTHISIS PULMONALIS. 129 

Bayle. From both these works, an attentive reader 
may derive useful information. But of all the treatises 
I have ever seen on consumption, what I hold to be 
the most valuable is a work published last year by Dr 
Thomas Young of London, physician to St George's 
Hospital, entitled A Practical and Historical Treatise 
on Consumptive Diseases, deduced from original obser- 
vations, and collected from authors in all ages. In that 
elaborate work, the truly learned author has given a 
medical history of pulmonary consumption from the 
days of Hippocrates, to the publication of DrSou- 
they's observations in 1814. He has there presented 
to the reader the most interesting facts respecting the 
history,nature, and treatment of this formidable disease, 
recorded by authors of the greatest celebrity, of every 
age and nation, who have cultivated medicine as a 
science. It is therefore a work which, in my opinion^ 
will be highly instructive, not only to the young practi- 
tioner, but which may be perused with advantage, even 
by the oldest and most experienced of the profession. 

Although there is but too much reason to fear, that, 
notwithstanding the united labours of all who have 
written upon this subject, pulmonary consumption 
will still continue to be a very dangerous and fatal dis- 
ease, yet I would fain hope, that, duringthe present pe- 
riod, some progress has been made in the mode of com« 



130 MODES OF CURE, &C. 

bating this formidable complaint with success. And 
I need not add, that, although in the course of nature, 
my employment in the practice of medicine is now 
drawing very near to a conclusion, it will yet afford me 
very great sat^fact ion to learn still farther improve- 
ments from succeeding writers on Phthisis Pulmonale 



APPENDIX 



APPENDIX. 



As the Memoirs of the Caledonian Horticultural 
Society will not probably be in the possession of ma- 
ny medical practitioners, it is presumed that the fol~ 
lowing extract from that work may not be unaccept- 
able to the reader. 



Observations on the preparation of Soporific Medicines 
from common Garden Lettuce, by Dr. A. Duncan, 
senior, read in the Caledonian Horticultural Society, 
6th March , 1810, and printed in the 1st volume of 
their Memoirs, p. 160. et seq. 

Opium, or the inspissated white juice which ex- 
udes from the capsule of the papaver somnifenwu 

M 



134 APPENDIX- 

when wounded, has long been allowed to be one of the 
most useful articles employed in the alleviation or cure 
of diseases. The high encomium bestowed upon it 
by the illustrious Sydenham,* has been fully confirm- 
ed by the testimony of succeeding practitioners in 
every nation. It is, however, much to be regretted, 
that there are individuals of the human species, 
with whom, fro m peculiarity of habit, opium seldom 
fails to produce distressing consequences. There 
are also conditions of disease, in which it maybe 
very necessary to induce sleep, or allay pain, though 
circumstances occur by which the use of opium 
at that time is contra-indicated. Hence it has long 
been a desideratum in the healing art, to discover 
other powerful quieting' medicines. For, although 
it is hardly to be expected that an article will ever 
be discovered, so extensively useful as opium, yet 
a good soporific may be found, which, with some, 
will have less influence, either as exciting sickness 
at stomach, as occasioning confusion of head, or as in- 
ducing a state of constipation. 

It has been the opinion of many, that all the milk} 
juices spontaneously exuding from wounded vegetables 
possess somewhat of the same sedative power with the 

* " Ita necessarium est Opium, in hominis periti manu, u" 
"sine iilo mancasit, ac claudicet medicina." — Sydenham, d~ 
Dvsenteria arm 1660, &"V 



q£ 



aITENDIX. lob 

milky juice of the poppy. Few plants in Britain 
afford such milky juice more copiously than the com- 
mon garden lettuce, the lactuca sativa of Linnaeus; 
and every one must have observed, that this juice when 
spontaneously inspissated by the heat of the sun on the 
wounded plant, soon assumes the dark colour of opium; 
while, at the same time, it possesses in a high degree 
the peculiar, and, I may say, specific taste, which dis- 
tinguishes that substance. Besides this, it is a well 
known fact, that lettuce was much used by the ancients 
as a soporific. 

These circumstances led me to turn my thoughts on 
some method of collecting and preparing this exuda- 
tion, that I might try its effects in the practice of me- 
dicine. And, after several trials of different modes of 
preparation, those which I shall now briefly describe 
are the best methods I have yet been abie to discover. 

I dedicated to this experiment, in my garden at St 
Leonard's Hill, near Edinburgh, a small bed of that 
variety of lettuce, which is commonly known among 
gardeners by the name of ice lettuce. I allowed the 
plants, about a hundred in number, to shoot up, till the 
top of :he stem was about a foot above the surface of 
the ground. I then cut off about an inch from the ?op 
of each. The milky juice immediately began to rise 



136 APFENBIX. 

above the wounded surface. Though then of a wmte 
appearance, it had next day formed a black, or dark- 
coloured incrustation, over the surface where the stem 
was cut off. I founjd it impossible to separate this by 
scraping, as is done with the milky juice exuding from 
the head of the poppy, when it has assumed the form 
of opium. I therefore cut off with a sharp knife a thin 
cross slice of the stem, to which the whole of the dark 
coloured opium-like matter adhered. This was thrown 
into a wide-mouthed phial, about half filled with 
weak spirit of wine, the alcohol dilutum of the Edin- 
burgh Pharmacopoeia^ formed of equal parts of rectified 
spirit and water. By this menstruum, the whole black 
incrustation on the thin slice of the stalk was dissolved; 
and the spirit, as may be readily concluded, obtained 
both the colour and taste of the black incrustation. 

Each of my plants, in consequence of the fresh 
wound inflicted by the removal of the thin cross slice, 
afforded a fresh incrustation every day. And by throw- 
ing these into the phial, I soon obtained what I con- 
cluded to be a saturated soluiion of the exudation from 
the lettuce, or rather of the milky juice in its inspissat- 
ed state. It was then strained off, to separate the 
pure solution completely from the thin slices of the 
stalk. To this strained spiri% ^vhich had nearly both 
the appearance and taste of the ordinary Jaudarwm of 



APPENDIX, 13T 

the shops, I have given the name of solutio spirilnosa 
succi spissati lactucce. From trials made with this so- 
lution, both on myself and others, 1 have no doubt that 
it is a powerful soporific. But to obtain a form in 
which it might be exhibited, with greater certainty as 
to the dose, I evaporated the spirit, and thus brought 
the residuum to a dry state. In this state, it has very 
much the appearance of the opium imported into Bri- 
tain, particularly of that which is imported from Ben- 
gal, and which is a much softer substance than the 
Turkey opium. To this opium-like substance, I have 
given the name of lactucarium. And from some trials 
which I have made with it, when exhibited under the 
form of pills, it appears to me to be little inferior in so- 
porific power to the opium which is brought from Ben- 
gal, which in general is much inferior in power to 
Turkey opium. 

From the lactucarium thus obtained,, I have formed 
a tincture, by dissolving it to the extent of one ounce 
in twelve of weak spirit, which is the proportion of 
opium to spirit, in the liquid laudanum of the Edin- 
burgh college. To this formula I have given the name 
of tinctura lactucarii. I consider it as the best formula 
I have yet been able to contrive for obtaining the sopo- 
rific and sedative powers of the lactuca sativa. And 
in different cases, I have, I think, seen manifest good 

m 2 



138 APPENDIX 

effects from it, both as inducing sleep, allaying muscu- 
lar action, and alleviating pain, the three great quali- 
ties of opium, which demonstrate it to be one of the 
most powerful sedatives. At present, however, I in- 
tend nothing more but to communicate to the Caledo- 
nian Horticultural Society a method of preparing a so- 
porific medicine from common lettuce. For ascertain- 
ing more fully its medicinal effects, I am at present en- 
gaged in a series of trials, w T hich may. perhaps, be like- 
wise communicated to them. 

Meanwhile it will afford me great satisfaction, if 
the above short account shall draw the attention of 
others, particularly of professional gardeners, to the 
same subject, and shall lead to the discovery of a bet- 
ter method of obtaining an useful medicine, from a 
plant so easily cultivated in every garden. Perhaps 
this important object might be somewhat forwarded, if 
the Caledonian Horticultural Society were to propose 
a prize, as a reward to the person who should be most 
successful in preparing a soporific medicine from the 
milky juice of the lactuca. But it should be an essen- 
tial condition of that prize, that he should send them, 
not only a specimen of the substance prepared, but 
slso an exact account of his method of preparing it 



APPENDIX, 139 

In consequence of the above suggestion, the Caledo- 
nian Horticultural Society, at the Quarterly Meeting 
on the 6th of March, 1810, agreed to propose a Prize 
Medal for each of the two following questions: 

1. For the best method of preparing a soporific me- 
dicine from the inspissated white juice of the common 
garden lettuce. Specimens of the medicine to be 
produced. 

2. For the best method of preparing opium in Bri- 
tain, and the most advantageous manner of cultivating 
poppies for that purpose. 



In consequence of the Memoir on Lactucarium, read 
to the Caledonian Horticultural Society by Dr Dun- 
can, two distinguished professional gardeners, Mr 
Henderson at Brechin, and Mr Gorrie at Rait, have 
transmitted to the Society excellent specimens of let- 
tuce-opium, with an account of their methods of pre- 
paring it. From what they have done, there is reason 
to hope, that it may be easily prepared. to a great ex- 
tent in Britain, 



140 APPENDIX. 

Mr Thomas Carmichael, teacher of languages, 
at the Sheriff-Brae, Leith, has, during the summer sea- 
son, 1813, prepared for sale a considerable quantity of 
lactucarium; and three different preparations from that 
article, compounded according to the annexed formu- 
lae, may be had at the shop of Mr William Moffat. 
apothecary, Nicolson's Street, Edinburgh. 

Mr Moffat has now also for sale another preparation 
from lettuce, which the Royal College of Physicians 
in Edinburgh have agreed to introduce into a new edi- 
tion of their Pharmacopoeia, at present in the press, the 
succus %pissatus lactucce sativcc. This is prepared in 
the same manner as succi spissati of the aconitum, 
belladonna, hyoscyamus, &c; and has been usefully 
employed both under the form of pills and lozenges, for 
the preparation of the last of which a formula is sub- 
joined. 

From the second volume of the Memoirs of the Cale- 
donian Horticultural Society it will be seen, that a 
Prize Medal, for a pa*per on the first, of these subjects, 
was awarded to Mr Henderson at Brechin, 8th De- 
cember 1812; and for a paper, on the last subject, to 
Dr Howison at Douglas, on the 14th of December 
181 J. These papers have since been published in the 
Memoirs of the Society. 



APPENDIX. (41 

Further Observations on the preparation of a Soporific 
Medicine from common Garden Lettuce, communicat- 
ed to the Caledonian Horticultural Society by Dr 
Duncan, senior, and read 14th November, 1811, 

From the writings of the most eminent medical au- 
thors, it . appears, that garden lettuce was employed 
many centuries ago, for the purpose of procuring sleep, 
Galen, who flourished about the commencement of 
the Christian era, mentions it frequently in his writ- 
ings. And it is said, that in an advanced period of 
life, when distressed for want of sleep, he used it with 
success.* 

Among the moderns this article has not been altogether 
neglected. Some observations and experiments have 
been made repecting its medical powers, both in Eng- 
land and in America; particularly by Dr Cox of Phila- 
delphia, and Dr George Pearson of London. 

About two years ago, I read to the Caledonian 
Horticultural Society, a short account of a method of 

* " Hypnoticam esse jam cognoverunt veteres : Celsus, qui 
papaveri ides adjung t; Gaienusj qui sibi ipsi sene.v insomnts 
vesper: actuca comesa somnum conciliavit." — Mdkbat, Appa° 
figtue Medic, vol i. p. 109. 



142 



APPENDIX. 



preparing a soporific medicine from this plant. That 
account so far engaged the attention of the Society, 
that they proposed a prize medal as an honorary re- 
ward, for the best method of preparing a soporific me- 
dicine from the inspissated white juice of the common 
garden lettuce. 

I am happy to learn, that some ingenious men have 
not been neglectful of this Subject; and I would fain 
hope, that even our inconsiderable premium may lead 
to an honourable and useful competition. Among 
others, I have myself made farther trials with this 
[ vegetable; and I now present to the Society specimens 
of five different preparations of lettuce, all of which 
may, I think, be usefully employed in the practice 
of medicine. 

Of the method of preparing the first, second, and 
third of these, viz. 1. The spiritous solution, or tinc- 
ture of the dried juice; 2. The extract, which I for- 
merly styled lactucarium, and which is prepared by 
the evaporation of that solution or tincture; and, 3. 
The tincture of the lactucarium, which is prepared by 
dissolving Lhat substance in diluted spirits of wine, 
I have nothing to add to what I formerly related to 
the society. I may, however, observe, that, from re- 
peated trials, I have found all of them to be usefu! 



APPENDIX. 14; 



soporifics. But the preparation of these requires much 
time, and great attention; and in preparing lactuca- 
rium, it may be easily injured by the improper applica- 
tion of heat. 



The two additional preparations which I now 
present to the society, the inspissated juice, and the 
tincture of the leaves of lettuce, may be made very 
easily, and at a very trifling expence. Although not 
so powerful as the solution or extract, prepared 
from the inspissated milky juice; yet they will, I am 
persuaded, be found, upon trial, to be highly useful in 
the practice of medicine. 

Method of preparing the Inspissated Juice of Lettuce, 
or the Succus Spissatus Lactucaz recentis. 

Take any quantity of the leaves and stalks of the 
lettuce, when the plant is nearly ready to flower. 
Bruise them well, and including them in a hempen 
bag, compress them strongly till they yield their juice. 
Let this juice be evaporated in flat vessels, heated with 
boiling water. Let the evaporation be continued till 
the expressed juice be reduced to the consistence of 
thick honey. 

According to the trials which I have made, twelve 



144 APPENDIX 

pounds of lettuce will yield about eight ounces of in 
spissated juice. 

Method of preparing the Tincture of Lettuce leaves . 
or the tinctura foliorum siccatorum lactucoz sativce. 

To one ounce of the dried leaves and stalks of the 
lettuce cut down, add eight ounces of the diluted 
alcohol of the Edinburgh Pharmacopoeia. Let the 
vessel containing this mixture be kept for a week in 
a warm place, shaking it frequently. Let the liquor 
then be strained through paper, and kept for use. 
About fifty drops may be taken for a dose. 



Additional observations on the Lactuca, presented to the 
Caledonian Horticultural Society, by Dr Duncan. 
sen. and read May 1, 1812. 

In two former short communications to the Society, 
I have given an account of a method of preparing, from 
the common garden lettuce, different articles, which 
may, I am convinced, be employed with advantage in 
the practice of medicine. To these I have given the 
following names. 



APPENDIX. 145 

1 . Solutio sued spissati lactucat. 
Prepared from the inspissated juice spontaneously 
exuding from the plant when wounded. 

2. Lactucarium, 

An extract prepared by evaporating the above solu- 
tion or tincture. 

3. Tinctura laciucarii, 

Prepared by dissolving lactucarium in proof-spirit 
of wine. 

4. Succus spissatus lactucw. 

Prepared by inspissating the expressed juice of the 
recent plant. 

5. Tinctura foliorum lactucce, 

Prepared by extracting the active powers of the 
lettuce, from the leaves of the dried plant, by warm 
infusion in proof-spirit. 

To my former observations I can now add, that, 
during the course of last winter, I have made many 
trials of these articles, both in hospital and in pri- 
vate practice. I have particularly employed the first 
and the fourth of these preparations, in the clinical 
wards of the Royal Infirmary, where their effects were 



146 APPENDIX. 

observed by many attentive and ingenious students, 
They have witnessed the benefit which may be deriv= 
ed from them in procuring sleep, in alleviating pain, 
and in allaying inordinate action, particularly trouble- 
some cough. I am therefore not without hopes, that 
when the experiments I have made are more generally 
known, they may have the effect of calling the atten- 
tion of other medical practitioners, and of some intelli- 
gent gardeners, to a subject, which, in my opinion, 
is of considerable importance. 



Respecting the preparation of the lactucarium, I 
have lately been favoured, by my ingenious friend 
Mr John Young, surgeon in Edinburgh, with the 
following letter: 

To Dr Duncan, senior. 

Edinburgh, 5th October, 1816. 
Dear Sir, 

Your zeal in promoting the interests of science, and 
of that branch of knowledge in particular which belongs 
to our profession, induces me to lay before you the 
annexed observations, on a new method of collecting 
the milky juice of the lactuca sativa, and also of the 
papaver somniferum, both in Britain and other eoun- 



APPENDIX. 147 

tries. I am induced to take this step, because I know, 
that if you think my method of collection of -any use, 
it cannot be recommended to the public through a bet- 
ter channel than you; and because I know that you 
have, for some time past, been engaged in a series of 
trials, for ascertaining more fully the medicinal effects 
of lactucarium. In the mean time, I shall be glad to 
know your opinion with regard to the observations I 
now send you: And I shall be glad to have the ho- 
nour of communicating to you whatever else may oc- 
cur to me on this subject. 

I am, dear Sir, 

With much esteem, yours, 

John Younc- 



148 APPENDIX, 

Observations on the method of obtaining Lactucarium, o. 
Lettuce opium, from the Lactuca Sativa of Linnceus. 
the common Garden Lettuce. By Mr John Young. 
Surgeon in Edinburgh. 

Edinburgh, October, 1816. 

In collecting lactucarium last year, according to the 
methodrecoinmendedby Dr Duncan, senior, in the Me- 
moirs of the Caledonian Horticultural Society, I found, 
that it not only occupied much time, but that I was of- 
ten disappointed of the substance which I expected to 
obtain, from its being washed off by rain. It occurred 
to me, that the milky juice of the lettuce might be im- 
mediately collected from the plant in great abundance, 
by absorbing it on cotton soon after it exudes from the 
plant, and while it yet continues in a liquid state; and 
by afterwards inspissating it by a moderate heat, com- 
municated from a water or vapour bath. 

I accordingly adopted that method this year. I had 
the ice-lettuce planted in rows; and when the top of 
the stem was about a foot above the ground, I then cut 
off about an inch from the top of each plant. The 
milky juice immediately began to rise above the wound- 
ed surface. I cut off the tops of all the plants before 
I began to coHect. But after the portion which had 



APPENDIX. 149 

exuded was removed by the cotton, I found that the 
milky juice ceased to exude, until I had made another 
wound. I began to collect, at the end of the border, 
where I made the first incision, and then cut off a thin 
cross slice from the stem of each plant, leaving fresh 
wounds as I went along. These I found covered with 
milky juice each time when I returned to where I set 
out. But after going round the plants about five or six 
times, in the way mentioned, they ceased to give out 
any more milky juice at that time. But this process 
may be repeated two or three times in a day. 

In the manner above described, I have collected more 
of the milky juice in one day, than I did last year in 
five days, when it was not removed till it had acquired 
a dry state and black colour. Having mentioned to a 
friend my mode of collecting the milky juice in its re- 
cent state, by means of cotton, he suggested the use of 
a wet sponge for that purpose. This, I find, answers 
better than the cotton; the juice being both more com- 
pletely removed from the plant, and more easily ex- 
pressed, than from the cotton. The milky juice col- 
lected in this way into a tea-cup, or any similar vessel. 
soon acquires a dark brown colour, like opium obtain- 
ed from the papaver somniferum, and has all its other 
sensible qualities. Hence it may justly be distinguish- 
ed by the title of lettuce-opium, although, perhaps. 
x2 



150 



APPENDIX. 



less confusion would arise, from employing the name 
which Dr Duncan has adopted, that of lactucarium. 

From what I have observed respecting this method 
of collecting the milky juice from the lactuca sativa, 
it is my opinion, that in the same manner, opium might 
be procured in this country from the papaver somnife- 
rum, equal, if not superior, to any foreign opium Dr 
James Howison, who was for some time employed by 
the Honourable East India Company to superintend 
the preparation of opium in Bengal, has published an 
essay on that subject in the first volume of the Memoirs 
of the Caledonian Horticultural Society, page 368,* 
which contains many important observations respecting 
the preparation of opium in Britain. But the method 
of collecting the milky juice from the plant by means 
of cotton or a sponge, possesses many advantages which 
cannot be obtained by the flask which he proposes, or 
by the knife and cup of the Hindoos: For by their 
method of collection, a considerable quantity of the 
milky juice, exuding from the head of the poppy, must 
be lost. But by preparing opium in Britain, a still 
greater advantage would accrue. It would be obtain- 
ed in a perfectly pure state, which is by no means the 
case with the opium which is brought to us from 
abroad. 

* A Prize Medal was awarded to Dr Howis©^ by the Caledo 
ledonian Horticultural Society for this communication. 



APPENDIX. 151 



By Mr Young's process, I have no doubt that lactu- 
carium may be obtained, with much more ease, and to 
a greater extent, than by the method which was com- 
munica'ed to the public in the former edition of these 
observations. But in whatever way the lactucarium or 
lettuce-opium may be prepared, I am convinced, both 
from my owrif experience, and from the observations 
of several of my friends, that from the common lettuce 
cultivated in our own gardens, we may obtain an use- 
ful sedative medicine for allaying pain, and procuring 
sleep in those constitutions with which opium, the 
most useful of all medicines yet discovered, cannot be 
employed without producing very disagreeable conse- 
quences. In proof of this, I shall only subjoin the fol- 
lowing letter from my intelligent friend Dr James 
Anderson, an eminent accoucheur in Edinburgh, who 
has very extensive practice in the diseases of women 
and children, and who has often employed lactucarium^ 
particularly in puerperal cases. 



152 



APPENDIX. 



To Dr Duncan, senior. 

Edinburgh, 28th October, 1816. 

My Dear Sir, 

In consequence of a conversation with you some 
some years ago, I was led to pay particular attention 
to the effects of lactucarium in certain cases. 

I have seldom been disappointed when it was exhibit- 
ed in a proper dose, to promote rest, and allay irrita- 
bility. I have observed that, when the dose had not 
been sufficient to procure sler>p, my patients still obtain- 
ed from it comparatively easy nights, being freed from 
hot skin, inclination to toss about, and similar uneasi- 
ness. 

For these four years I have used it with success for 
such patients as disagree with opium. In no case 
have I observed consequent nausea, costiveness, or irri- 
tation of the skin, produced by it. 

It is gratifying to observe with how much thankful- 
ness it is taken by such valetudinarians as are excluded 
from the use of opium from its distressing effects upon 
them. Two ladies of my acquaintance, the one sub- 
ject to spasms in the stomach, and the other to frequent 
attacks of irregular gout, have for these three years 



APPENDIX. 153 

reared lettuce plants, and made a tincture for them- 
selves, which they have employed in their own cases, 
with great relief: And from what I have seen, I have no 
doubt, that when lactucarium becomes more an object 
of attention with medical practitioners, it will be gene- 
rally used where opium cannot be administered. 

I am, my dear Sir, 

Yours, with respect and esteem, 

James Anderson, 



**te^ 



154 APPENDIX. 

Formula for different preparations of Lactucarium, a 
substance obtained from the inspissated white juice of 
the common garden lettuce, acordmg to the method 
described in the Memoirs of the Caledonian Horti- 
cultural Society, Vol. I. p. 160. 

1. TlN6TURA LACTUCARII . 

Recipe Lactucarii, unciam unam; 

Alcaholis diluti, libram unam. 
Digere per dies septem, et per chartam cola. 

2. Pilule lactucarii. 
Recipe Lactucarii, gr. xij. 

Pulveris radicis glycyrrhizae, scrupulos 
duos. 
Subige cum syrupo simplice, ut fiat massa, ad pilulas 
formandas apta; et divide in pilulas duodecim. 

3. TROCHISCI GLYCYRRHIZiE CUM LACTUCARIO. 

Recipe Lactucarii, drachmas duas; 

Tincturae toluiferae balsami, unciam di- 

midiam; 
Syrupi simplicis, uncias octo; 
Extracti glycyrrhizae glabrae, aqua calida 

moliti, 
Gummi mimosae Niloticae in pulverem triti, 

ntriusque uncias quinque 



APPENDIX. 155 

Primd, tere lactucarium bene cum tinctura; dein 
paulatim admisce syrupum et extractum; postea sen- 
sing insperge pulverem gummi mimosas Niloticae; et 
tandem exsicca, ut fiat massa, in trochiscos formanda, 
singulos grana decern pendentes. 

4. Trochisci succi spissati LAduaaE. 
Recipe Succi spissati lactucae; 

Extracti glvcyrrhizas glabrae; 
Pulv. gummi acacias Arabicae, singulorum 
partem unam. 
Hasc optime terantur simul, et cum aqua fiat massa, 
in trochiscos formanda. 



THE END. 




\/* %/'-•; 




»< ;1 










vf S 



- "<£* 



^76 




